Medical documentation and patient record systems
Rebecka Janols
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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.