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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...
Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Purpose of Health Records I01:11

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
Health Information Technology and Healthcare Information System01:30

Health Information Technology and Healthcare Information System

Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Purpose of Health Records II01:19

Purpose of Health Records II

Health records serve various essential purposes in the healthcare system. Here are some key purposes:
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:

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TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
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Medical record: systematic centralization versus secure on demand aggregation.

Catherine Quantin1, David-Olivier Jaquet-Chiffelle, Gouenou Coatrieux

  • 1Inserm, U866, Dijon, F-21000, Univ de Bourgogne, Dijon, F-21000, France. catherine.quantin@chu-dijon.fr

BMC Medical Informatics and Decision Making
|March 24, 2011
PubMed
Summary
This summary is machine-generated.

This study introduces a secure, on-demand system for retrieving scattered patient medical data. The proposed Medical Record Search Engine (MRSE) offers a pragmatic alternative to centralized systems, improving data accessibility for healthcare professionals.

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Area of Science:

  • Health Informatics
  • Medical Record Management
  • Data Security

Background:

  • Patient medical histories are often fragmented across multiple healthcare institutions.
  • Accessing scattered patient data presents significant challenges for healthcare providers.
  • Existing centralized systems face issues with standardization, privacy, and security.

Purpose of the Study:

  • To develop a pragmatic and secure on-demand system for gathering patient medical history data.
  • To enable secure retrieval of scattered health information for medical professionals.
  • To address the limitations of centralized medical record systems.

Main Methods:

  • Proposed an alternative approach using an on-demand system with a specialized search engine.
  • Utilized data 'as is' without requiring standardization or centralization.
  • Implemented pseudonymized patient identities to ensure privacy.

Main Results:

  • Developed Medical Record Search Engines (MRSE) to retrieve patient information from various hospitals.
  • MRSEs provide requested information to healthcare professionals using pseudonymized data.
  • The system bypasses many difficulties of centralized architectures but requires professional data validation.

Conclusions:

  • An on-demand system for gathering patient information is highly beneficial.
  • This low-cost, pragmatic alternative to centralized records can be developed quickly.
  • The system offers potential for future enhancements and should be considered by health authorities.