Tuyển tập báo cáo các nghiên cứu khoa học quốc tế ngành y học dành cho các bạn tham khảo đề tài: Patient-recorded outcome to assess therapeutic efficacy in protoporphyria-induced dermal phototoxicity: a proposal
Tuyển tập các báo cáo nghiên cứu về y học được đăng trên tạp chí y học Critical Care giúp cho các bạn có thêm kiến thức về ngành y học đề tài:Electronic patient record use during ward rounds: a qualitative study of interaction between medical staff...
Chapter 7 - Introduction to practice partner. After studying this chapter, you should be able to: Explain how the use of access levels protects the privacy of information in a patient record, describe the purpose of the dashboard, explain where patient registration information is stored and accessed, explain the function of the Chart Summary,...
Compare the effect of reduce intracranial pressure by mannitol and NaCl3% in the acute elevated intracranial pressure on stroke patient. Record the change in the hemodynamic status and laboratory date during the treatment of osmotic therapy.
Chapter 9 - Maintaining patient records. In this chapter you will explain the purpose of compiling patient medical records, describe the contents of patient record forms, describe how to create and maintain a patient record, identify and describe common approaches to documenting information in medical records,...
Chapter 9 - Maintaining patient records. After studying this chapter you will be able to understand: Explain the purpose of compiling patient medical records, describe the contents of patient record forms, describe how to create and maintain a patient record, identify and describe common approaches to documenting information in medical records,...
Modern medicine is characterized by the continuously growing
spectrum of improving diagnostic methods and therapeutic processes.
It keeps getting more complicated and confusing and therefore
also needs more order.
The main goal of medical documentation is to provide information
for the adequate care of patients. Carefully carried out written
records like a patient history, physician indexes, or, more recently,
patient databases serve to reach this goal.
This series is directed to Healthcare professionals who are leading the transformation
of health care by using information and knowledge. Historically, the series was
launched in 1988 as Computers in Health Care, to offer a broad range of titles:
some addressed to specific professions such as nursing, medicine, and health
administration; others to special areas of practice such as trauma and radiology; still
other books in the series focused on interdisciplinary issues, such as the computerbased
patient record, electronic health records, and networked Healthcare systems.
The best way to learn about a subject, I now realise, is to write a book about it.
Another good way is to teach it. In 1999, University College London (UCL)
started a postgraduate programme in Health Informatics. As the programme
director it was largely my responsibility to define the curriculum, a somewhat
daunting task in a new and ill-defined subject.
It is widely believed that broad adoption of Electronic Medical Record Systems (EMR-S) will lead to significant healthcare savings, reduce medical errors, and improve health, effectively transforming the U.S. healthcare system. Yet, adoption of EMR-S has been slow and appears to lag the effective application of information technology (IT)
There are no typical retention periods for program records because they are unique to
the individual office. They represent the reason the office exists and their retention is
usually specified in some statute or regulation that established the office or program. A
few program records may be identified for permanent retention however most will be
retained for a specific number of years, or as perpetual records with an “Active” period,
just like administrative records.
Most program records are large in volume and may be required much longer than
This series is directed to healthcare professionals who are leading the
transformation of health care by using information and knowledge to advance
the quality of patient care. Launched in 1988 as Computers in Health Care, the
series offers a broad range of titles: some are addressed to specific professions
such as nursing, medicine, and health administration; others to special areas of practice such as trauma and radiology.
Chapter 3 - Essential documentation. After completing Chapter 3, the students will be able to: Describe the basic features of SpringCharts EHR, describe the history of SpringCharts EHR, apply user preferences, carry out setting up and editing patients, use pop-up text, explain the concept of an electronic chart, use the electronic chart’s face sheet, use the SpringCharts EHR care tree.
Chapter 5 content: Recording vital signs, documenting telephone calls, creating a letter to a patient or about a patient, creating a letter unrelated to a patient, sending a test report to a patient, Creating an excuse note and order form for a patient, using practice guidelines, using “my websites”, using the calculator utilities.
Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O).
Chapter 9 - Routine documentation. After completing Chapter 9, the students will be able to: Use the ToDo List feature, use internal messages, carry out accessing and completing the patient’s immunization record, carry out creating and distributing a patient instruction sheet, use the draw program to develop illustrations to enhance documentation.
Chapter 10 - Patient education. Chapter 10 content: patients’ rights and nurses’ responsibilities related to education; accreditation requirements for patient education; patients’ learning needs; nursing diagnoses, outcomes, and interventions for patient education; implementation, evaluation, and documentation of patient education.
Chapter 11 - Nurse note documentation, level 3. After completing Chapter 11, the students will be able to: Carry out documentation of patient education and response, identify patient response to interventions, carry out documentation re-assessment/revision of goals, use Todo/Reminders within the Nurse Note.
Chapter 12 - Advanced EHR functionality. After completing Chapter 12, the students will be able to: Use EHR to order diagnostic tests, carry out a chart evaluation, use a new note to create an addendum to a nurse note, carry out printing a nurse note, carry out exporting and printing elements of a patient’s chart.