Authoring Patient Records: An Interactive Guide

Authoring Patient Records: An Interactive Guide
Author: Michael P. Pagano
Publisher: Jones & Bartlett Publishers
Total Pages: 210
Release: 2010-02-11
Genre: Medical
ISBN: 1449663281

Authoring Patient Records: An Interactive Guide presents both the theory and rationale for the process of developing medical records, as well as opportunities for readers to practice the new skill. Each chapter discusses how to use the authoring process to create effective records, using examples and sample documents to help illustrate potential problems and solutions. This text has an interactive format including margin notes to help the reader assess his/her understanding, as well as opportunities to practice the authoring process being discussed. An instructor’s manual for online use is also included. Authoring Patient Records: An Interactive Guide is relevant to the training and work of: MDs, PAs, NPs, RNs, PTs, and RTs. The text will be a helpful resource in teaching health care students and as a reference for health care practitioners.

Authoring Patient Records

Authoring Patient Records
Author: Michael P. Pagano
Publisher: Jones & Bartlett Publishers
Total Pages: 210
Release: 2010-02-11
Genre: Medical
ISBN: 1449611052

Authoring Patient Records: An Interactive Guide presents both the theory and rationale for the process of developing medical records, as well as opportunities for readers to practice the new skill. Each chapter discusses how to use the authoring process to create effective records, using examples and sample documents to help illustrate potential problems and solutions. This text has an interactive format including margin notes to help the reader assess his/her understanding, as well as opportunities to practice the authoring process being discussed. An instructor’s manual for online use is also included. Authoring Patient Records: An Interactive Guide is relevant to the training and work of: MDs, PAs, NPs, RNs, PTs, and RTs. The text will be a helpful resource in teaching health care students and as a reference for health care practitioners.

Personal Health Records

Personal Health Records
Author: Mohammad Al-Ubaydli
Publisher: John Wiley & Sons
Total Pages: 136
Release: 2011-07-05
Genre: Medical
ISBN: 1444348256

Patient-controlled personal health records are the key to successful interaction between physician and patient. They form the core for joined-up communication throughout health organizations. Still, the very name is capable of alarming both patient and doctor. Are they reliable? Are they complete? Are they confidential? Where do you access them? For the doctor, additional concerns surround the implementation: how do you include these online tools in your busy schedule? How much will they add to your existing spend on information technology? Can you get paid for doing all this extra work? Now you can find dependable answers to all of these questions. Written by a physician who has developed his own personal health records software for patients and doctors to interact, Personal Health Records: A Guide for Clinicians explains how to get the best from your patient's records and how to put the information to good use, helping both your patient and yourself to a more effective and efficient outcome in any clinical situation. “The author is a clinical academic, patient and pioneer in his field and does a grand job of explaining the ins and outs of PHRs in a non-patronising manner for the non-tech savvy” – From a review published in Health Services Journal by: Dr Emma Stanton, Commonwealth Fund Harkness Fellow and Specialist Registrar at South London and Maudsley NHS Foundation Trust

Secondary Analysis of Electronic Health Records

Secondary Analysis of Electronic Health Records
Author: MIT Critical Data
Publisher: Springer
Total Pages: 435
Release: 2016-09-09
Genre: Medical
ISBN: 3319437429

This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.

Integrated Electronic Health Records

Integrated Electronic Health Records
Author: M. Beth Shanholtzer
Publisher: McGraw-Hill Education
Total Pages: 304
Release: 2020-06-11
Genre: Medical
ISBN: 9781260082265

Developed as a comprehensive learning resource, this hands-on course for Integrated Electronic Health Records is offered through McGraw Hill's Connect. Connect uses the latest technology and learning techniques to better connect professors to their students, and students to the information and customized resources they need to master a subject. Both the worktext and the online course include coverage of EHRclinic, an education-based EHR solution for online electronic health records, practice management applications, and interoperable physician-based functionality. EHRclinic will be used to demonstrate the key applications of electronic health records. Attention is paid to providing the "why"behind each task, so that the reader can accumulate transferable skills. The coverage is focused on using an EHR program in a doctor's office, while providing additional information on how tasks might also be completed in a hospital setting.

The Computer-Based Patient Record

The Computer-Based Patient Record
Author: Committee on Improving the Patient Record
Publisher: National Academies Press
Total Pages: 257
Release: 1997-10-28
Genre: Medical
ISBN: 030957885X

Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Writing Patient/Client Notes

Writing Patient/Client Notes
Author: Ginge Kettenbach
Publisher: F.A. Davis
Total Pages: 295
Release: 2016-05-11
Genre: Medical
ISBN: 080365846X

Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

The Patient-Centered Approach to Medical Note-Writing

The Patient-Centered Approach to Medical Note-Writing
Author: Christopher J. Wong
Publisher: Springer
Total Pages: 0
Release: 2024-03-10
Genre: Medical
ISBN: 9783031436321

Patients are increasingly accessing their own electronic health record, ushering medical chart notes out of the cloistered purview of clinicians and into the age of transparency. With the recognition that patients are reading what is written about them, there is a need for a comprehensive reference on best practices for writing medical notes in this new era. The Patient-Centered Approach to Medical Note-Writing covers important topics including stigmatizing language, the electronic health record, the different parts of a typical medical note, mental health, substance use, difficult encounters, and how to address electronic communication such as test results and patient messages. This book serves as a vital reference for students, residents, fellows and practicing clinicians.

Key Capabilities of an Electronic Health Record System

Key Capabilities of an Electronic Health Record System
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 36
Release: 2003-07-31
Genre: Medical
ISBN: 0309185432

Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.