Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.902174
Shanmei Sun, Kexin Liu
AbstractObjective. To explore the methods of improving the medical record archiving management so as to effectively solve the problem of difficult medical record archiving and further guarantee timely reuse of medical records. Methods. Hospital questionnaires are performed according to clinical and objective reasons causing overdue in medical record archiving, and outstanding problems are found out using a root cause analysis (RCA) method and intervened. Result. The intervened effects are tracked. The results show that the three-day archiving rate of medical records rises 1.26% under conditions and that the year-on-year medical record recycling amount in the next year increases to 1,979 copies. Conclusion. The way of thinking is changed using a RCA quality management mode, in-depth analysis is performed, and the fundamental constraint factors are found, which are the effective means of solving the problem of difficult timely archiving of medical records in medical record management.
{"title":"Significance of Root Cause Analysis Method in Medical Record Archiving Management","authors":"Shanmei Sun, Kexin Liu","doi":"10.3109/23256176.2014.902174","DOIUrl":"https://doi.org/10.3109/23256176.2014.902174","url":null,"abstract":"AbstractObjective. To explore the methods of improving the medical record archiving management so as to effectively solve the problem of difficult medical record archiving and further guarantee timely reuse of medical records. Methods. Hospital questionnaires are performed according to clinical and objective reasons causing overdue in medical record archiving, and outstanding problems are found out using a root cause analysis (RCA) method and intervened. Result. The intervened effects are tracked. The results show that the three-day archiving rate of medical records rises 1.26% under conditions and that the year-on-year medical record recycling amount in the next year increases to 1,979 copies. Conclusion. The way of thinking is changed using a RCA quality management mode, in-depth analysis is performed, and the fundamental constraint factors are found, which are the effective means of solving the problem of difficult timely archiving of medical records in medical record management.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"63 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133495429","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.904576
Ying Fu, Lihua Nie, Naxin Cai
AbstractObjective. To objectively evaluate the quality and effectiveness of teaching and identify the problems in the teaching process, and to carry out the comprehensive analysis and evaluation of the final examination paper of medical record informatics. Method. The final examination paper of medical record informatics is analyzed through the education survey. Result. The average score of the examination paper is 70.6, and the examination results obey normal distribution. The examination paper has the features of moderate difficulty, general discrimination and good reliability. The proportion of easy questions is too large, and the proportion of the relatively difficult questions should be increased. Conclusion. The proportion of the relatively difficult questions on the examination paper should be increased promptly, so that the examination paper with moderate difficulty can objectively reflect the actual level of the students, thereby improving the quality of teaching.
{"title":"Analysis and Evaluation of Final Examination Paper of Medical Record Informatics","authors":"Ying Fu, Lihua Nie, Naxin Cai","doi":"10.3109/23256176.2014.904576","DOIUrl":"https://doi.org/10.3109/23256176.2014.904576","url":null,"abstract":"AbstractObjective. To objectively evaluate the quality and effectiveness of teaching and identify the problems in the teaching process, and to carry out the comprehensive analysis and evaluation of the final examination paper of medical record informatics. Method. The final examination paper of medical record informatics is analyzed through the education survey. Result. The average score of the examination paper is 70.6, and the examination results obey normal distribution. The examination paper has the features of moderate difficulty, general discrimination and good reliability. The proportion of easy questions is too large, and the proportion of the relatively difficult questions should be increased. Conclusion. The proportion of the relatively difficult questions on the examination paper should be increased promptly, so that the examination paper with moderate difficulty can objectively reflect the actual level of the students, thereby improving the quality of teaching.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"71 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129846041","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.902175
Qianjun Zhong, Hui-Tzu Huang
AbstractWith the continuous expanding of the process of health care reform, the application of an Electronic Medical Record (EMR) system is becoming an important measure of constructing medical information; at present, China is vigorously promoting the EMR system, but this effort is not fast enough, so much so that many clinicians are falling short of recognizing the EMR, thus making many mistakes, and having insufficient and incorrect understanding of the true meaning of the EMR. Clinicians are also underutilizing the structural characteristic of the EMR. In order to tackle these problems, appropriate solutions and countermeasures are being proposed, and some of these are improving publicity and training, stating the legal issues about the clinical use of the EMR, improving the functioning of the EMR, etc. As part of the process of the continuous expanding of health care reform, it is imperative for hospital leaders and clinicians to pay serious attention to the EMR system so that it can be developed rap...
{"title":"Problems of Clinicians in Using Electronic Medical Records and Countermeasures","authors":"Qianjun Zhong, Hui-Tzu Huang","doi":"10.3109/23256176.2014.902175","DOIUrl":"https://doi.org/10.3109/23256176.2014.902175","url":null,"abstract":"AbstractWith the continuous expanding of the process of health care reform, the application of an Electronic Medical Record (EMR) system is becoming an important measure of constructing medical information; at present, China is vigorously promoting the EMR system, but this effort is not fast enough, so much so that many clinicians are falling short of recognizing the EMR, thus making many mistakes, and having insufficient and incorrect understanding of the true meaning of the EMR. Clinicians are also underutilizing the structural characteristic of the EMR. In order to tackle these problems, appropriate solutions and countermeasures are being proposed, and some of these are improving publicity and training, stating the legal issues about the clinical use of the EMR, improving the functioning of the EMR, etc. As part of the process of the continuous expanding of health care reform, it is imperative for hospital leaders and clinicians to pay serious attention to the EMR system so that it can be developed rap...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130699284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.904578
Guang-xia Li, Y. Feng, Wen-jiao Xie, Xiao-Fen An, Dongxia Li
AbstractObjective. To conduct telephone follow-up of health education for elderly patients with hypertension and analyze the effect of the education. Method. A total of 638 cases of elderly patients with hypertension admitted to our hospital from January 2009 to January 2013 were randomly divided into a control group and an intervention group. The patients in the control group received routine discharge guidance while those in the intervention group received regular telephone follow-up based on the health education that was imparted. Then, the parameters such as the rate of patients’ satisfaction with the hospital service, rate of awareness of hypertension related knowledge and the patients’ compliance to treatment were evaluated after six months. Results. The rate of the patients’ satisfaction with the hospital services was 98.43% in the intervention group, which was higher in comparison with the control group. The awareness rates of knowledge such as the risks of hypertension, standardized and rational ...
{"title":"Analysis of the Effect of Health Education with Telephone Follow-up for Elderly Patients with Hypertension","authors":"Guang-xia Li, Y. Feng, Wen-jiao Xie, Xiao-Fen An, Dongxia Li","doi":"10.3109/23256176.2014.904578","DOIUrl":"https://doi.org/10.3109/23256176.2014.904578","url":null,"abstract":"AbstractObjective. To conduct telephone follow-up of health education for elderly patients with hypertension and analyze the effect of the education. Method. A total of 638 cases of elderly patients with hypertension admitted to our hospital from January 2009 to January 2013 were randomly divided into a control group and an intervention group. The patients in the control group received routine discharge guidance while those in the intervention group received regular telephone follow-up based on the health education that was imparted. Then, the parameters such as the rate of patients’ satisfaction with the hospital service, rate of awareness of hypertension related knowledge and the patients’ compliance to treatment were evaluated after six months. Results. The rate of the patients’ satisfaction with the hospital services was 98.43% in the intervention group, which was higher in comparison with the control group. The awareness rates of knowledge such as the risks of hypertension, standardized and rational ...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"56 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124815083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.904555
Hong-bin Zhu
AbstractIn this article, the author, combining the experience of applying the modularized electronic medical records and related documents in the teaching process: causing a sense of inertia in students, medical records being short of individual characteristics, contents of medical records being piled and self-contradictory, and a weakening of the basic clinical skills of students. Related countermeasures are brought forward in the article: giving play to the subjective initiative of students, enhancing the teachers’ sense of responsibility and their teaching capability, and enhancing communication between students and teachers. Knowledge of the problems and the countermeasures are beneficial for the improvement of clinical teaching.
{"title":"Problems of Applying Electronic Medical Record Templates to Clinical Teaching, and the Countermeasures","authors":"Hong-bin Zhu","doi":"10.3109/23256176.2014.904555","DOIUrl":"https://doi.org/10.3109/23256176.2014.904555","url":null,"abstract":"AbstractIn this article, the author, combining the experience of applying the modularized electronic medical records and related documents in the teaching process: causing a sense of inertia in students, medical records being short of individual characteristics, contents of medical records being piled and self-contradictory, and a weakening of the basic clinical skills of students. Related countermeasures are brought forward in the article: giving play to the subjective initiative of students, enhancing the teachers’ sense of responsibility and their teaching capability, and enhancing communication between students and teachers. Knowledge of the problems and the countermeasures are beneficial for the improvement of clinical teaching.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"25 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132891624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.904552
Luyong Li, Hao Yu, Xi'ran Liu
AbstractStrengthening the management of professional technical files in a hospital is an important guarantee for the scientific management of a hospital. By analyzing related problems existing in the management of professional technical files, we propose that the hospital should take the electronic human resources management system as a carrier, integrate the medical record information and the scientific research and teaching information, and establish a data system of professional technical electronic files. Further, we could make effective use of professional technical files and improve work efficiency.
{"title":"Establishment and Management of the Electronic Files of Professionals in Hospitals","authors":"Luyong Li, Hao Yu, Xi'ran Liu","doi":"10.3109/23256176.2014.904552","DOIUrl":"https://doi.org/10.3109/23256176.2014.904552","url":null,"abstract":"AbstractStrengthening the management of professional technical files in a hospital is an important guarantee for the scientific management of a hospital. By analyzing related problems existing in the management of professional technical files, we propose that the hospital should take the electronic human resources management system as a carrier, integrate the medical record information and the scientific research and teaching information, and establish a data system of professional technical electronic files. Further, we could make effective use of professional technical files and improve work efficiency.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125896044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-31DOI: 10.3109/23256176.2014.902176
M. Tan, Wei-Ren Wu, Meixin Cao
AbstractObjective. To investigate the influence of the psychological contract theory on management quality of medical records. Method. The changes experienced by clinical medical workers during job burnout and the quality of the data on medical records in a year before and after the implementation of the psychological contract management in a hospital are analyzed. Result. After the implementation of the psychological contract management on the aspect of job burnout, the number of workers with emotional exhaustion decreased significantly in comparison with the previous number. The two dimensions of reduced personal accomplishment and emotional exhaustion significantly reduced in comparison with the previous situation. The recovery rate of medical records within three days increased by 17 percentage points; the quality of the medical records also improved; compared with the previous situation, the first-grade rate of medical records increased by 5 percentage points, and the modification rate reduced by 13 ...
{"title":"Influence of Improving Job Burnout through Psychological Contract Theory on Management Quality of Medical Records","authors":"M. Tan, Wei-Ren Wu, Meixin Cao","doi":"10.3109/23256176.2014.902176","DOIUrl":"https://doi.org/10.3109/23256176.2014.902176","url":null,"abstract":"AbstractObjective. To investigate the influence of the psychological contract theory on management quality of medical records. Method. The changes experienced by clinical medical workers during job burnout and the quality of the data on medical records in a year before and after the implementation of the psychological contract management in a hospital are analyzed. Result. After the implementation of the psychological contract management on the aspect of job burnout, the number of workers with emotional exhaustion decreased significantly in comparison with the previous number. The two dimensions of reduced personal accomplishment and emotional exhaustion significantly reduced in comparison with the previous situation. The recovery rate of medical records within three days increased by 17 percentage points; the quality of the medical records also improved; compared with the previous situation, the first-grade rate of medical records increased by 5 percentage points, and the modification rate reduced by 13 ...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"42 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126226155","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-12DOI: 10.3109/23256176.2014.896630
Zhang Jufen, Du Jing, Li Jian, Jiaxin Gao, Ai'min Chen
AbstractThe article introduces the recovery of medical records by the client browser mode, to solve the long-standing problem of low work efficiency in medical record recovery, caused by the staff of the medical record department recording and confirming the medical records on the computer after taking the medical records back to the medical record department. Through the improvement of the medical record recovery process, the confirmation link of medical record recovery is carried out in the ward in advance; in July, the medical record recovery rate increased from 93.57% in 72 h (Grade B) to 82% in 48 h. It further improves the medical record recovery rate, recovery work quality and efficiency, and promotes the medical record management level. The use of the client browser mode is feasible in the realization of medical record recovery in the ward, and one can vigorously promote the use of this method in hospital.
{"title":"Recovery Management of Medical Records Based on Client Browser","authors":"Zhang Jufen, Du Jing, Li Jian, Jiaxin Gao, Ai'min Chen","doi":"10.3109/23256176.2014.896630","DOIUrl":"https://doi.org/10.3109/23256176.2014.896630","url":null,"abstract":"AbstractThe article introduces the recovery of medical records by the client browser mode, to solve the long-standing problem of low work efficiency in medical record recovery, caused by the staff of the medical record department recording and confirming the medical records on the computer after taking the medical records back to the medical record department. Through the improvement of the medical record recovery process, the confirmation link of medical record recovery is carried out in the ward in advance; in July, the medical record recovery rate increased from 93.57% in 72 h (Grade B) to 82% in 48 h. It further improves the medical record recovery rate, recovery work quality and efficiency, and promotes the medical record management level. The use of the client browser mode is feasible in the realization of medical record recovery in the ward, and one can vigorously promote the use of this method in hospital.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"2013 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127362186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-12DOI: 10.3109/23256176.2014.897489
Wenfeng Li, Muhui Cao
AbstractObjectives. To quantitatively assess the quality of homepages of medical records, for further improvement. Methods. Twenty quality control points were set up according to “Some Regulations in Instructions for Filling in Homepages of the Medical Records”, issued by the National Health and Family Planning Commission of the PRC in 2012; and a Homepage Inspection Marking Table was developed and used for the quality control of the homepages of 167 medical records with the same date of discharge. Results. The pass rate for the filling-in of the homepages of medical records was 95.2%; the rate of omission of the patient's basic information was the highest, accounting for 29.9%; the rate of incorrect diagnostic conformances was up to 12.6%; and the rate of omission of the pathology number, the reason for damage and poisoning, and the anaphylactic drug, accounted for 10.8%. Conclusions. The quality of the homepages of the medical records can be improved through strengthening the learning assessment and the...
{"title":"Quality Management of Homepages of Medical Records","authors":"Wenfeng Li, Muhui Cao","doi":"10.3109/23256176.2014.897489","DOIUrl":"https://doi.org/10.3109/23256176.2014.897489","url":null,"abstract":"AbstractObjectives. To quantitatively assess the quality of homepages of medical records, for further improvement. Methods. Twenty quality control points were set up according to “Some Regulations in Instructions for Filling in Homepages of the Medical Records”, issued by the National Health and Family Planning Commission of the PRC in 2012; and a Homepage Inspection Marking Table was developed and used for the quality control of the homepages of 167 medical records with the same date of discharge. Results. The pass rate for the filling-in of the homepages of medical records was 95.2%; the rate of omission of the patient's basic information was the highest, accounting for 29.9%; the rate of incorrect diagnostic conformances was up to 12.6%; and the rate of omission of the pathology number, the reason for damage and poisoning, and the anaphylactic drug, accounted for 10.8%. Conclusions. The quality of the homepages of the medical records can be improved through strengthening the learning assessment and the...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"63 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121568322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-03-12DOI: 10.3109/23256176.2014.896636
Kaihuan Yu, Y. Xiong, Chang Mao
AbstractThe publication of electronic medical records involves the medical services record being published for patients in real time during the entire diagnostic and treatment process, which not only helps the medical institutions standardize the diagnosis and treatment activities of medical staff and upgrade the quality of medical records, but also respects the patient's right of informed consent and the patient's right of self-determination, increases the mutual trust between doctors and patients, and helps to reduce and deal with risks in medical disputes. Therefore, the publication of electronic medical record content is inevitable. However, in the publication process, the training provided to the medical staff regarding information publication and the relevant laws and regulations, should be strengthened, and suggestions for establishing a quality control system for electronic medical records and the steps to implement them, are put forward.
{"title":"Feasibility Study on Publication of Electronic Medical Records and Prevention of Doctor-Patient Disputes","authors":"Kaihuan Yu, Y. Xiong, Chang Mao","doi":"10.3109/23256176.2014.896636","DOIUrl":"https://doi.org/10.3109/23256176.2014.896636","url":null,"abstract":"AbstractThe publication of electronic medical records involves the medical services record being published for patients in real time during the entire diagnostic and treatment process, which not only helps the medical institutions standardize the diagnosis and treatment activities of medical staff and upgrade the quality of medical records, but also respects the patient's right of informed consent and the patient's right of self-determination, increases the mutual trust between doctors and patients, and helps to reduce and deal with risks in medical disputes. Therefore, the publication of electronic medical record content is inevitable. However, in the publication process, the training provided to the medical staff regarding information publication and the relevant laws and regulations, should be strengthened, and suggestions for establishing a quality control system for electronic medical records and the steps to implement them, are put forward.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"193 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116346781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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