Showing 9 results for Medical Record
R Sharifian , M Ghazi Saedi ,
Volume 1, Issue 1 (12-2007)
Abstract
Background: In recent years lots have been done for hospital automation but this non harmonized actions leads to different software usage and entrance of different data into the system when partly is not useful . In this way, usage of soft wares in medical records specialty in the high loaded reception and recording will decrease defect in registration and storage of medical data. Using computerized system which cover applied soft wares could decrease many problems in medical data records. Any research in medical record area needs to be fed with data there fore it should be to use and evaluation of computerized systems.
Method: This cross sectional study was conducted in reception and recording department teaching hospitals of Tehran University of Medical Sciences (TUMS), Iran, using check list and direct collection of the data in the hospital. We used descriptive statistics tools to analysis the data.
Results: Specialized hospital and general hospital use computerized system for medical record with percents of 49.06% and 40.73% respectively .search of the input data and output data were considered as 66.7%.
Conclusion: The usage of automation in reception and recording departments of TUMS hospitals was low and even the operating system was not capable to register the patients data. Even though a few humble of systems in medical records awards were set which would be the source of some problems is saving and processing the data.
H Dargahi , N Masuri , R Safdari , S Fazaeli , M Yousefi ,
Volume 4, Issue 2 (9-2010)
Abstract
Background and Aim: Analysis of efficiency in hospitals, as the most expensive operating unit of the health system, is very important. This costly unit has several departments that one of them is medical records. This study is trying to analyze the efficiency of medical records department for the enhancement of using medical records facilities.
Materials and Methods: In this study, technical, scale and managerial efficiency of medical records department has been studied by data envelopment analysis method, and assuming the scale efficiency variable and the input axis. Information used in this study was the input variables (number of technician personnel and lower and Master of Science personnel and higher), output variables (number of emergency and outpatient and inpatient medical records and the number of filing unit visitors to respond) during 2007-2009.
Results: The average technical efficiency of medical records departments is 84 percent, that indicates there is at least 16 percent capacity for an increase in performance. Average of management and scale Performance in units during the 3 years of study are 95 and 89 percent respectively. Most input surplus is relevant to technician and lower personnel. The average performance of these units in general hospitals is 80 percent and in specialized activities is 92 percent.
Discussion and Conclusion: Relationship between studied indicators in this study with performance medical records departments showed that using such as employee personnel with undergraduate degrees and higher and educated in medical records filed, the use of managers with enough experience in this department and more use of computer systems for unit activities can fill 16 percent capacity of performance improvement in these units.
Nilufar Masouri, Fateme Sadeghi, Elham Khayyamdar,
Volume 5, Issue 3 (11-2011)
Abstract
Background and Aim: Information is a factor for organizations success and organizations try to stay in this competitive world. In each organization, there are sections that have special role in information aspect in hospitals and healthcare centers, this role is for medical record section which organizes all of the patients' health care information. Paying attention to function quality in this section(medical record) is very important. Since health ministry introduce(EFQM) as an Excellence Model for hospitals, there fore, the role and importance of medical record section in implementation of this model and its criteria is determined.
Materials and Methods: All of the information databases was collected and those which were appropriate were selected. Then according to the article's goal, proper keywords were selected and documented through comparing with MESH. Finally related articles in credible journals were used in two Persian and English languages.
Results: After determining all the concepts and criteria of EFQM and matching them to the medical record section's goals, task's and functions, feasibility study of EFQM implementation in medical record section, is approved. With this comparism, importance of this section's role in signification model scores hospitals quality of performance is determined.
Mostafa Langarizadeh , Elahe Gozali , Farahnaz Sadoughi ,
Volume 7, Issue 4 (11-2013)
Abstract
Background and Aim: Development of information and communication technology has led to enormous changes in different areas. Electronic medical records system is valuable to access patient data in hospitals. This study aimed to investigate and compare the educational hospitals of Uemia University of Medical Sciences in case of technical, organizational and legal to establish the system.
Materials and Methods: The study was a descriptive cross-sectional study. The study population consisted of 98 senior and central managers. In this study population census was used and the entire population were considered as the sample. A questionnaire was used for data collection, which included two sections in order to determine the level of research community awareness and to analyze the standards related requirements for the implementation of the system. Validity and reliability were assessed and the data was analyzed by SPSS.
Results: Sample awareness in 5 hospitals of this study was moderate. In terms of requirements, there was a significant difference between the means of Electronic Medical Records in terms of three variables between hospitals "D" and the rest of the hospitals. And no significant difference was seen among other hospitals.
Conclusion : Three hospitals, "a", "c" and "b", among five studied hospitals are in preparation for the deployment of electronic medical records. Other two hospitals were not prepared. However, the implementation of electronic medical records, increases health care quality, patient safety and patient care and also decreases health costs. So it is suggested that hospitals do necessary efforts to establish EMR.
Mohammadhiwa Abdekhoda, Maryam Ahmadi, Mahmodreza Gohari, Alireza Noruzi,
Volume 10, Issue 2 (5-2016)
Abstract
Background and Aim: Inclusive implementation of Electronic Medical Records (EMR) is more serious because of physicians’ perception. This study was carried out to identify the effects of organizational contextual factors on physicians’ perception regarding EMR’s adoption in 2013 (The merger of Tehran University and Iran).
Materials and Methods: This was a descriptive, analytical and cross- sectional study in which a sample of 270 physicians working in hospitals affiliated to Tehran University of Medical Sciences was selected. Physicians’ perception toward adoption of EMR has been assessed by Technology Acceptance Model or TAM questionnaire and organizational context variables. Collected data were analyzed by SPSS. The study model was tested by Structural Equation Modeling (SEM) and represented by AMOS.
Results: The findings showed that perceived usefulness (PU), perceived ease of use (PEOU), management support, physicians’ involvement, physicians’ autonomy, and physician- patient relationship have direct and significant effect on physicians’ attitudes toward EMR adoption. However, training has no significant effect on TAM variables. Moreover, the results showed authorizing proposed conceptual path model explained about 56 percent of the variance of EMR adoption.
Conclusion: The present study revealed that organizational context factors had significant effect on physicians’ attitude toward EMRs’ adoption. The study clearly identified six relevant factors that affected physicians’ perception regarding EMR adoption. These factors should be considered when comprehensive implementation is pursued.
Narjes Mirabootalebi, Maryam Ahmadi, Mohammad Dehghani, Shahram Khani, Mohsen Azad,
Volume 10, Issue 5 (1-2017)
Abstract
Background and Aim: Electronic Medical Record system collects and stores laboratory data, digital images and electronic versions. It plays a major role in reducing medical errors and duplication and health care providers immediate access to patient medical records. This study aimed to examine the viewpoints of Hormozgan University of Medical Sciences' administrators on the role of electronic Medical records system.
Materials and Methods: The study was a descriptive-analytical research to examine the viewpoints of Hormozgan University of Medical Sciences' administrators and physicians on the role of electronic medical records system. The study population consisted of 61 managers, matrons and health information managers of Hormozgan hospitals and 121 faculty physicians and residents. Data collection tool was a researcher-made questionnaire. The validity was determined and verified by content validity method and experts' views. Cronbach's alpha coefficient was used for assessing reliability, which was 83%. Data collected from the questionnaires was analyzed using SPSS software and descriptive statistics and analytical statistics.
Results: Results indicated that "data management" (N=146) with 77.5%, "job objectives and processes" (N=160) with 87.9%, "communication" (N=163) with 89.6%, "data privacy and security" (N=152) with 83.1% had the most important roles in the health system.
Conclusion: Generally, managers and physicians attitudes about the role of electronic medical records system in the health system was evaluated satisfactorily. According to the advantages of the system and removing major obstacles in its implementation, a new step would be taken in order to promote health.
Maryam Nakhoda, Abbas Sheikh Taheri, Madihe Esfandiari Pour,
Volume 11, Issue 1 (5-2017)
Abstract
Background and Aim: Organizations must collect, process and analyze different types of necessary information and give them to managers and other individuals. Such information includes the management of medical records and documents in insurance companies. This study aims to evaluate the potentialities of medical records management electronic systems in such companies.
Materials and Methods: In this cross-sectional applied research, the systems existing in insurance companies were checked using researcher-made checklists to study the capabilities of medical records management electronic systems in all governmental and private insurance companies of Gorgan. For data-analysis, descriptive statistics (frequency, percentage) was used.
Results: In data register and entry, the share of insurance companies as well as the amount of deductions was 92%. In the ability to search, store and retrieve, the search based on the names of persons had the highest percentage (100%). Security was one of the features considered in the software of insurance companies. In the reporting section, the possibility to report the titles of medical documents was 92%. Lack of physical and electronic documents manageability through check-out method was 14%.
Conclusion: In terms of functional capabilities, softwares observed in insurance companies have both strong points (security feature) and weak points (classification and indexing capabilities). The management of medical records and documents can be enhanced in the softwares of insurance companies by using the mentioned capabilities of the existing softwares.
Marjan Ghazi Saeedi, Gholam Reza Esmaeili Javid, Niloufar Mohammadzadeh, Hamide Asadallah Khan Vali,
Volume 14, Issue 5 (1-2021)
Abstract
Background and Aim: Diabetes is one of the most common metabolic diseases in the world, of which one of the most common and painful complications is diabetic foot ulcer. The accuracy and comprehensiveness of the contents of electronic medical record is effective in improving the quality of treatment and the care of diabetic foot ulcer patients. The aim of this study is to determine the minimum data set (MDS) essential for diabetic foot patients' electronic medical records.
Materials and Methods: In this descriptive-analytical study, authoritative internet and library resources were studied to collect diabetic foot ulcer information elements. Fourteen physicians and nurses working and collaborating with the Wound Healing Center affiliated to Academic Center for Education, Culture and Research (ACECR) were selected for clinical survey, and 5 health information technology specialists of Tehran University of Medical Sciences (TUMS) were chosen for demographic information survey. The study tools were a researcher-made questionnaire, CVR content validity method and test-retest method for reliability.
Results: Out of 23 information elements surveyed in demographic section, cases above 99% of the agreement were selected. Also, out of 86 information elements of the clinical section, more than 51% of the cases were selected. Clinical experts included 6 wound specialists, 4 general practitioners and 6 nurses. In the demographic information section, the lowest agreement was related to the element of identity and Education level with 20% agreement. In clinical information, the lowest agreement was related to surgery, leech therapy and MRI of the foot with 0% and PRP, G-CSF, Sono-Doppler liver with 14%.
Conclusion: The minimum information elements of diabetic foot ulcer electronic medical record were divided into history, wound information, lower limb information, paraclinical results, wound management, and follow-up in clinical section; and in demographic information section, they were divided into identity, admission, finance, reporting, and system capability. The proposed model for manual and electronic medical records is available.
Mohamad Jebraeily, Shima Touraj, Farid Khorrami,
Volume 17, Issue 3 (8-2023)
Abstract
Background and Aim: In the health system, reimbursement methods are an important criterion for the allocation of resources and the performance of service providers. The use of diagnosis-related groups (DRG) system reduces the length of stay and additional costs of the patient, prevents unnecessary treatment, increases resource efficiency and transparency of health care services. The development of the DRG system focuses on the accurate documentation of medical records and the correct coding of diagnoses and procedures. The purpose of this research is to evaluate the documentation and coding requirements of medical records in the implementation of a payment system based on diagnosis-related groups in Iran.
Materials and Methods: This research was descriptive-cross-sectional and was conducted in 2022. The data collection tool was a researcher-made checklist, the validity of which was confirmed based on the opinion of experts (health information management health economics) and its reliability was obtained by calculating Cronbach’s alpha (0.83). The research population consisted of 418 medical records in five medical training centers affiliated to Urmia University of Medical Sciences, which were selected through stratified-proportional sampling. Data were analyzed using SPSS software.
Results: The results of the evaluation of the documentation and coding requirements of medical records for the implementation of the DRG system showed that the demographic/administrative variables including age, sex, type of admission, length of stay, health insurance, and doctor’s expertise were completely recorded. Evaluation of clinical variables also showed that the main diagnosis, main procedure, secondary diagnosis and other procedures were documented in medical records in 98%, 97%, 88% and 75% respectively. Regarding the coding of the main diagnosis and the main procedure, 100%, secondary diagnosis 68% and other procedures 80% have been done.
Conclusion: Considering that some essential clinical variables for the implementation of DRG, especially co-morbidities, complications and other procedures are not recorded separately and completely, therefore it is necessary to define separate information elements in medical records and HIS for accurate recording of these variables and proper interaction between coders and doctors is established to increase the possibility of correct coding. It is also suggested that the DRG system be implemented in our country in a phased and gradual approach so that necessary changes are made in the documentation process and hospital information systems.