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Data Reporting and Recording

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

Purpose of Health Records I

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:

Methods of Documentation II: POMR

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.

Methods of Documentation I: Source-Oriented Records

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:

Discharge Summary Forms

Discharge Summary Forms

The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
Here's a detailed look at the key components and guidelines for preparing a discharge summary:

Types of Records I: Unit and Nurses Records

Types of Records I: Unit and Nurses Records

Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...

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Generation of Comprehensive Thoracic Oncology Database - Tool for Translational Research

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HARVEST, a longitudinal patient record summarizer.

Jamie S Hirsch¹, Jessica S Tanenbaum², Sharon Lipsky Gorman³

¹Department of Biomedical Informatics, Columbia University, New York, USA Division of Nephrology, Department of Medicine, Columbia University, New York, USA.

Journal of the American Medical Informatics Association : JAMIA

|October 30, 2014

Summary

HARVEST, a novel patient summarization tool, maintained clinical review performance and showed high user satisfaction. This informatics intervention facilitates efficient access to essential patient information at the point of care.

Keywords:

electronic health record natural language processing summarization visualization

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Published on: September 26, 2018

Area of Science:

Clinical Informatics
Health Information Technology
Medical Informatics

Background:

Clinicians require efficient methods for reviewing complex longitudinal patient records.
Current patient data systems can be fragmented and time-consuming to navigate.
There is a need for point-of-care tools that summarize and visualize patient information effectively.

Purpose of the Study:

To describe the HARVEST (Health Assessment Record Visualization and Exploration System) tool.
To conduct a formative evaluation of HARVEST's effectiveness and usability.
To gather feedback for iterative improvements of the patient summarization tool.

Main Methods:

HARVEST utilizes natural language processing and problem salience computation for patient record summarization.
Information is presented through interactive, temporal visualizations of longitudinal patient data.
Clinical usability was assessed via task-based chart reviews and questionnaires with physician participants.

Main Results:

HARVEST presents patient data longitudinally via a timeline and problem cloud.
Task-based evaluations showed performance and time-to-completion were maintained compared to standard systems.
Physician participants reported high satisfaction and interest in using HARVEST in daily practice.

Conclusions:

HARVEST is ready for wider deployment and offers valuable feedback for future optimization.
The tool addresses the need for efficient point-of-care patient information review.
HARVEST serves as an informatics intervention to study and improve clinician access to patient data.