Medical documentation and patient record systems

Medical documentation and patient record systems

Rebecka Janols

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Institutionen för informationsteknologi | www.it.uu.se

After today… You will know what a care process is

Example from primary care and hospital

You will know more about medical records What it looks like Who is documenting What kind of information it contains How it can be structured

You will understand some problems with paper-based and computer-based medical records

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Care process and medical documentation

Medical record documentation is an important part of the care process. It is relevant facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes.

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The care process in primary care (vårdcentral)

The patient has a problem

Examination and initial diagnosis

Meets physician

Calls primary care, to get advice from the nurse.

The patient is healthy

Referral to specialty care, or treatment at primary care.

Decision about treatment, start the treatment

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Example: Hospital (specialty care)Registration process Patient information – administrative and clinical data Initial examination – anamnesis and clinical examination Decision on care commitment, is the patient at the right

care unit.

Diagnostic process Actions: tests and examinations Make a diagnosis Decision about treatment/therapy

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Hospital

Treatment/therapy Treatment/therapy plan Treatment/therapy actions Result?

Discharge process Epicrisis, a summing up of a medical case history Prognosis Re-use documented data Follow-up

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A patient´s clinical picture

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What is a patient record? What is a patient record?Patient record is a systematic documentation of a

patient's medical history and care

It contains:

Administrative data

Anamnesis

Status

Diagnostic actions,

test result, x-ray

Diagnosis

Therapy plan

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Patient recordsGoal Collect relevant data for supporting

– treatment – decision making– evaluation– quality making– research – education

Better quality of the care process Unbroken care process

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Who document?

There are legal regulations for some care providers to document.

Physicians – long documentation history Nurses Allied Health Personnel

Psychologist Physiotherapist Welfare officer

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Structure of patient records

Time-oriented medical record Problem-oriented medical record with

SOAP structure. Subjective Objective Assessment Plan

Source-oriented medical record

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Paper-based patient record

Negative It can only be at one place at one time Missing medical records Unstructured Hard to read Hard to get a good overview Many different records Quality assurance is difficult Hard to archive

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Hard to archive…

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Computer-based patient record

Often used in primary care, less used at hospitals.

Are the care providers satisfied? Bad human-computer interaction (low

usability) The computer is not working Slow computer programs Different care providers have different needs Bad authorization systems Not patient-centered

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Multiple computer systems

There are multiple systems for primary care and the whole care process. But there are only 5 big systems for the whole care process in Sweden: TakeCare (Profdoc) Cambio Cosmic (Cambio) Melior (Siemens) VAS (Norrbottens läns landsting) BMS Cross (SysTeam)

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Example: Cambio COSMIC

Concept: One patient – One medical record Clinical care support

Care documentation Order management (e.g radiology, lab,

consultations….) E-prescription Birth, Craft (surgery), Emergency, Link

Patient administration system (PAS) Resource planning Patient management

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Problems with computer-based patient records

User interface Safety Terminology Communication

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Problem 1: User interface

Overview of information Different type of information should be

presented: text, numbers, images, voice Different ways for data input:

Free text Structured Voice

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The patient card

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My master thesis

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Health issue patient overviewAlla HP Alla kontakter Visa

Diabetes 2003 -11 -03

HP 2 2003 -01 -03

Vårdgivare : 2005 -12 -03 Anna Ericsson (Läkare ), besök2005 -11 -04 Anna Ericsson (Läkare ), telefon2004 -10 -05 Karin EK (Distriktssköterska), besök

Aktuella mediciner : namn på mediciner (datum )

Tidigare mediciner : namn (start -slutdatum )

HP 3 2003 -11 -24

HP (990703 -040804 )

Tidigare Hälsoproblem

HP (start och slutdatum )

Aktuella Hälsoproblem (4 av 15 )

HP 4 2004 -11 -03

Skapa HP öppna

Patient info Livsstil :Alkohol : Tobak :Motion :Matvanor :

Viktigt :Mediciner :Allergier :Sjukskrivning : from -tom

Aktuella Remisser

Förnamn efternamnAdressTelefonnr :

Husläkare :Vårdcentral :

Hälsoproblems patientöversikt

Planerade kontakter (1 av 5)

(Senaste besöket visas först )2006 -10 -12

Distriktssköterska Anton Ek

Text ...

2005 -11 -17

Distriktssköterska Anton Ek

Osv…

Husläkare Karin Anderssons journal

071029Göra den årliga hälsoundersökningen

070505Diabetes kontroll , värdena såg bra ut .

Min journal Alla journaler (visar de senaste )

Aktuella läkemedel (3 av 5)

Nu

- 2005 -12 -03 Anna Ericsson (Läkare ), besök

-

----

Remiss till :Från :Knutet till HP 1

remisstext

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Health issue overviewPatientinformation

Alla vårdgivare Alla kontakter Visa

Vy för specifikt Hälsoproblem

Min ”att göra lista”

Min journal

Här står en sammanfattning från patientens förra besök hos mig ...

...

...

...

...

FiltreraAlla kontakter KategorierJournal

INFO om hälsoproblemet

Vårdplanering

Remisser :

Röntgen :

Labbprover :

Sök vårdplanering

Beställ röntgen

Beställ prover

Skriv remiss

Förnamn efternamnAdressTelefonnr :Husläkare :

Sjukskriven :Färdtjänst :Livsstil : rökn ,alkohol , motion etx

Mediciner :Allergier :

Text

Text

Text

1.2.3.4.etc

Nu

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Problem 2: Safety

Secrecy Accessibility Correctness Traceability

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Problem 3: Terminology

Confusion about the meaning of words. Different words for the same thing Same word for different things Free text

Different terminology between different roles.

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Anamnesis and status

Anamnesis: Physician: patient history in health careNurse: information about the patient

before the patient comes to the care

Status: Physician: objective findingsNurse: how the patient feels today

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Coding and Classification

The structure and level of details of the classification system depend on it’s purpose.

Many different coding and classification. ICD 10: Diseases and Related Health Problems ICF: International Classification of Functioning,

Disability and Health Planning patient care SNOMED-CT: Complete medical terminology

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Problem 4: Communication

Information in many systems Different architecture Different information structure

Integration & interoperability Technical interoperability Semantic interoperability

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Trends….

NPÖ – national patient overview European patient overview Medical account so the patient can get

access to her own medical record.

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Summary Patient records is a systematic documentation

of a patient's medical history and care. Physician, nurse, psychologist, physiotherapist,

welfare officer have to document. The medical record can be time,-problem,-

source oriented. The patients’ way through the health care is

called care process. The problem with the computer based medical

records are: User interface, Safety, Terminology, Communication.

Date post:	16-Oct-2021
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Medical documentation and patient record systems

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