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Documentation of Inpatient Medical Records: A Clinical Audit
Clinical AuditMustafa Sabir Abakar Awad,1 Mohamed FA Mohamednour,2 Fakher Aldeen Rafat,3 Mohaned Altijani,4 Abdelrahman Elfatih,3 Faris Jamalaldeen Mohammed Hamed,4 Abubakr Muhammed,5 Ibrahim Awad,6 Mohammed Alsiddig Alkheder,7 Mohammed Almubarak Omer Elhado,1 Aymen Yahya8 1Department of Community Medicine, Al-Neelain University Faculty of Medicine, Khartoum, Sudan;
Abubakr Muhammed +1 more
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International Journal of Health and Pharmaceutical (IJHP), 2022 Inpatient medical records have an important role as a source of data and health information for inpatients related to treatment and care planning. The main factor that causes problems in inpatient medical records is the undisciplined factor of the person in charge who handles patients in filling out medical records.
Ali Napiah Nasution
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MEDICALAUDIT OF INPATIENT MEDICAL RECORDS IN A TERTIARY CARE HOSPITAL
INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH, 2022INTRODUCTION: Medical record enable healthcare professionals to plan, evaluate a patient's treatment and ensures continuity of care. In a health care setting it is very crucial to maintain proper medical records as these documents are prerequisite for planning patient care and have legal ramiļcations. Therefore, medical audit plays an important role in
Deepti Sahran +2 more
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An Electronic Medical Record Training Conversion for Onboarding Inpatient Nurses
CIN: Computers, Informatics, Nursing, 2019In recent times, policies stemming from the American Recovery and Reinvestment Act of 2009 have served as a stimulus for healthcare organizations to adopt an electronic medical record. As a result, nurses are now more knowledgeable of and experienced with an electronic medical record.
Paula S, Smailes +4 more
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Patient access to medical records on a psychiatric inpatient unit
American Journal of Psychiatry, 1979The authors studied the effects of patient access to medical records during hospitalization in a psychiatric unit of a community general hospital. Questionnaires were completed by about 20 staff and 88 patients, and records were compared with those from an earlier period to note any changes in the written record.
E J, Stein +3 more
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Completeness of Medical Record Documents for Inpatient Kidney Failure at the Hospital
Proceedings of the International Conference on Nursing and Health Sciences, 2022 Health service providers are required to record all services provided to patients in the form of a complete medical record file. Incomplete filling of medical records can lead to misinformation used by health professionals in providing services or treatment plans. This study aims to determine the completeness of medical record documents and the factors
Nor Akmar Bt Mohd Yahya +2 more
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A reliable and record-based frailty assessment method for older medical inpatients
European Geriatric Medicine, 2020The comprehensive geriatric assessment (CGA) including frailty assessment is considered the gold standard of assessment in geriatric patients. The Multidimensional Prognostic Index (MPI) is a CGA-based bedside assessment tool. Older medical inpatients' medical records comprehensively describe the MPI-featured components. Consequently, MPI-based frailty
Troels K. Hansen +4 more
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Developing an Intuitive Intelligent Inpatient Medical Record System
2019Chimei Medical Center developed an intuitive intelligent inpatient medical record system which integrates structured, unstructured, and textual medical records and provides health insurance payment suggestions from the collaborative medical record writer's point of view.
Chia-Jung Chen +3 more
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Hospital Electronic Medical Record Use and Cost of Inpatient Pediatric Care
Academic Pediatrics, 2012Electronic medical record (EMR) systems are costly for hospitals to implement and maintain, and the effects of EMR on the cost of care for inpatient pediatrics remain unknown. Our objective was to determine whether delivering care with advanced-stage EMR was associated with a decreased cost per case in a national sample of hospitalized children.The ...
Myla D Ebeling +2 more
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Computer-based inpatient medical record in colorectal surgery
Diseases of the Colon & Rectum, 2000Clinical guidelines and care maps are important tools for improving quality of care and reducing costs. However, problems of quantity, quality, and accessibility of data recorded in the inpatient medical record have not been solved by the implementation of clinical pathways. Variance or "charting by exception" improves legibility, in part.
A, Nissan +3 more
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