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Medical Records in Family Practice

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Title: Medical Records in Family Practice


1
Medical Records in Family Practice
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(No Transcript)
3
Introduction
  • One of the most important tools used by family
    physicians in their practice are medical records
    and registers. They play essential roles in
    providing high quality health services in family
    practices.

4
Important uses of medical records and registers
in family practice
  • Providing data base for individuals and families.
  • Help in providing continuity care.
  • Help in vital statistics and decision making.
  • Used as documents for legal aspects and
    investigations if needed (medico legal aspect of
    care).
  • Help in auditing the health services.
  • Help in communicating the relevant facts
    concerning the patients care among the health
    team.

5
Criteria of good medical records
  • They are organized in logical and systematic
    manner.
  • They are complete.
  • They are simple and accurate.
  • They reflect the status of health and illness of
    the individuals and the communities.
  • They could be retrieved quickly.

6
Types of medical records and registers
  • 1- Family Health Records (FHR)
  • Family health records is a cumulative record
    (folder) of all family members. It gives data
    base about the family concerning
  • Type of house
  • Source of water, sanitation, lighting,
    ventilation.
  • Number of rooms
  • General health condition of the house
  • It contains the individual medical file of each
    member of the family providing with all data
    base.

7
2- Individual medical file
  • Individual medical files consists of the
    following sheets
  • Data base sheet contains
  • - date of birth,
  • - sex,
  • - marital status,
  • - educational status,
  • - occupation,
  • - medical,
  • - surgical,
  • - family,
  • - social history,
  • - drug history,
  • - history of allergies).

8
  • b) Physical examination sheet includes initial
    clinical examination as
  • - weight,
  • - height,
  • - BMI,
  • - eye,
  • - ear,
  • - nervous system,
  • - cardiovascular system,
  • - respiratory system,
  • - gastrointestinal system ,
  • - musculo-skeletal system.

9
  • c) Lab sheet include base line investigations
    such as
  • - urine,
  • - stool,
  • - blood and
  • - electrolytes.
  • d) Immunization sheet one sheet is provided to
    record the vaccines received by the individual
    child according to the date of administration/
    schedule.

10
  • e) Follow-up sheets they consist of many pages
    specified for follow-up visits. They contain
    space for
  • - date,
  • - vital signs,
  • - complains,
  • - clinical findings,
  • - diagnosis,
  • - treatment and
  • - appointment.

11
3- Problem (Patient) oriented medical record
(POMR)
  • A) PAMR contains two main components
  • - Data Base ( mentioned in the previous
    section)
  • - Problem List The problem list is
  • established after gathering of data base
  • and conducting the relevant clinical
  • examination and investigation.

12
  • Problem List could include
  • Pathological diagnosis (Thyroditis)
  • Disability (Deafness)
  • Deformity (Scoliosis)
  • Social (Poverty)
  • Psychological (Stress)
  • Clinical diagnosis (Hypertension)
  • Chronic symptom (Fatigue)
  • Active health problem (Bronchial Asthma)

13
  • B) Progress Note Progress note is designed to
    record the progress of the patient either for one
    or multiple problems in family practice. We
    usually use progress note depending on (SOAP
    system).
  • SOAP system stands for
  • Subjective
  • Objective
  • Assessment
  • Plan

14
For each problem, all these four elements should
be covered adequately.
  • Example
  • 45 years old male presented with cough for 3
    days. His chest examination revealed tachypnea
    and chest X showed left lung collapse . By using
    SOAP we can write the progress note of this
    patient as follows

15
  • Subjective What is the patient complaint?
  • (Cough)
  • Objective What is your clinical and lab
    findings? (tachypnea and left lung collapse)
  • Assessment Severely distressed patient due to
    left lung collapse (diagnosis and clinical status
    of the case.
  • Plan What should be done? Immediate referral to
    chest physician.

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  • S Cough for 3 days
  • O left lung collapse
  • A Severe distress due to collapse of
  • left lung
  • P Immediate referral to chest
  • physician

17
4- Flow Sheets
  • The flow sheets is a special sheet designed in
    relation to time. It is useful to find out the
    changes which occurred in a patient during short
    time. It has the following advantages
  • Quick data retrieval
  • Easy comparison of data
  • Easy reminder to health professionals

18
Flow sheet is usually to assess changes in
parameters such as
  • Blood pressure in hypertensive patients.
  • Blood sugar in diabetics
  • Input/output of urine in patients with acute
    renal failure

19
5- Special Lists
  • In family practice we use some special lists
    which are considered advantageous for patient and
    physician. These lists could be used to remind
    the physician or can be used for auditing. These
    lists include
  • Drug list (deals with the recording of all the
    drugs used by the patient ( name, dose,
    frequency, duration and route of administration).
  • Health education list ( deals with the title of
    the topics which were discussed with patient such
    as diabetic , asthmatics and obese patients)

20
6- Special forms
  • In family practice we use special forms for
    special patient. These forms could be part of the
    patients file. Example
  • Diabetic form which consists of many sheets
  • - the first one designated for data base
  • - the second page for follow-up visit
  • - the third page for annual check-up
  • - the fourth page for health education and
  • - the fifth page for drug list
  • Similar forms could be used for hypertensive,
    asthmatic and obese patients.

21
7- Special Registers
  • In family medicine and primary health care
    practice, we have many registers. These registers
    include
  • Birth register
  • Death register
  • Drugs register
  • Communicable disease register
  • Morbidity register
  • Immunization register
  • Referral register

22
Methods of medical records storage
  • Medical records can be stored or retrieved by
    using many methods. However, the most common two
    methods are
  • 1- Alphabetic filing system in this system the
    records are stored according to surnames of
    individuals. One of the common problems of this
    system is misfiling due to similarity of many
    names and ethnic group.
  • 2- Numeric system this system is commonly used
    in Medical Record Department. This system is
    rapid and accurate
  • .

23
Electronic Health Records
24
  • Before the development of the Electronic Patient
    Record (EPR), the technology used recording
    information was in the form of logs or diaries
    and
  • then the paper based patient record (PPR).
  • The record tells the story of the patient's
    journey through the healthcare system.
  • As a result the patient's record has now become
    an even more vital component in the provision of
    care.

25
  • Throughout the literature various terms are
    used to refer to automated health information
    systems
  • Electronic Patient record (EPR)
  • Electronic Medical Record (EMR)
  • Electronic Health record (EHR)

26
  • While these terms might be used interchangeably,
    there are slight differences between each system.
  • The common characteristics among them are they
    are all used to collect, store and manage patient
    information.

27
  • EPRs and EMRs contain patient information
    gathered and accessed from a single site, or
    information transferred from another site.
  • EHRs contain longitudinal personal health data
    across the continuum of care.
  • A network of EPRs and EMRs and other data stored
    through other clinical technology forms the HER.

28
  • Family practices (the first point of contact for
    many patients) are one of the most common
    settings for using EPRs.
  • In one country there should be one system
    implemented because with the implementation of
    different software there is complexity , such as
    the development of interfaces between the
    different software to enable the exchange of
    information.

29
  • As one of the key objectives of primary health
    care network is the integration of the continuum
    of services and information technology is viewed
    as one of the enablers for this integration.


30
  • An electronic health record (EMR) is a health
    record in digital format.
  • Electronic Health Record Is a most important tool
    for management of health care information in
    Health care Organizations, which provides online
    information in Health care facilities by using
    computer capabilities.

31
  • The electronic health record is a longitudinal
    collection of patient-centric, healthcare
    information, available across providers, and care
    settings.
  • It is a central component of an integrated health
    information system.
  • Electronic health records have the potential to
    save hundreds of hours of time, reduce cost of
    care, while improving patient care.

32
What is Interoperability?
  • In healthcare, interoperability is the
    ability of different information technology
    systems and software applications
  • to communicate,
  • to exchange data accurately, effectively, and
  • consistently, and
  • to use the information that has been exchanged.

33
Many benefits have been listed for the
utilization of electronic records
  • 1-instant and universal access to the patient
    record
  •  
  • 2- easier and quicker navigation through the
    patient record
  •  
  • 3- standardization of care among providers within
    the organization
  •  
  • 4- clinical data that is formatted to be easy to
    read and analyze
  •  

34
  • 5- reduction of paperwork, documentation, errors
    of filing activities
  •  
  • 6- alerts for medication errors, drug
    interactions ,patient allergies
  •  
  • 7- ability to electronically transmit
    information to other providers (assessments,
    history, treatments ordered, prescriptions, etc.)
  •  
  • 8- availability of clinical data for use in
    emergency

35
  • Applications

36
Medication Prescription
  •   A provider need only enter the information for
    a new prescription in the EMR, and that
    information is put on the patient's medication
    list.
  • The computer keeps track of when the prescription
    was written, the amount ordered (and later
    dispensed by the pharmacy), and the number of
    refills.

37
  • This capability saves time and improves
    communication with the patient, the pharmacist,
    and subsequent care providers.

38
 Medication Reconciliation
  • Managing multiple medications has increased the
    complexity of everyday patient care, especially
    care of the elderly.
  • The computer automatically checks for allergies
    and drug-drug interactions whenever a new drug is
    entered.
  • Although not all of the drug interaction alerts
    generated by the computer are clinically
    significant, the physician is prompted to
    consider the severity of the conflict and act
    accordingly.

39
  • If the physician is not knowledgeable about the
    type or cause of the interaction, a full
    explanation is available at the touch of a screen
    or with a single keystroke.
  • Pharmacy computers can keep track of
    prescription refills and alert the physician if
    the patient appears not to be taking a medication
    regularly. Other physicians can access the
    patient's medication profile in the EMR before
    prescribing a new drug.

40
Laboratory Test Results
  • Ordering laboratory tests and reviewing the
    results on a timely basis is an important
    component of patient care.
  • When laboratory tests are ordered electronically,
    the information is entered into a log, so that
    tracking the return and review of results is
    reliable and efficient.
  • For laboratory work that is performed in the
    office, such as blood tests, electrocardiograms,
    or radiographs, the computer automatically
    captures the proper information for billing
    purposes.

41
  • When results are returned to the physician, they
    are reviewed, and the patient can be notified of
    normal results or of the need for further
    testing.
  • An electronic method of tracking and obtaining
    results reduces delays in patient care provision
    and eliminates periods of concern for both
    patient and physician.

42
4-Record of Office Visit
  • An accurate record of the office visit is
    essential to the provision of good patient care.
    Various members of the clinical team enter
    information using templates.
  • The nurse or medical assistant may enter a
    portion of the note, such as
  • - the reason for the current visit,
  • - any concerns expressed by the patient,
  • - vital signs, and
  • - a review of current medications.
  •  

43
  • Physicians usually enter information about the
    patient's history and physical findings, along
    with diagnostic impressions or conclusions.
  • The traditional written narrative in the office
    visit note may easily obscure both normal and
    abnormal findings by embedding them in the middle
    of a paragraph or page, requiring the reader to
    scan the entire page to find the one piece of
    information the reader is looking for.
  • It would be far more efficient if normal and
    abnormal items were highlighted in some way for
    easy recognition.

44
  • Structured data entry allows information to be
    entered into the computer in a way that is easy
    to search and retrieve. Pick-lists allow
    clinicians to choose from standard complaints,
    history items, and physical findings in the
    course of constructing the final note.
  • There is also the option of displaying the note
    either in tabular form or in narrative form. With
    structured data entry, the necessary elements for
    coding and billing can be determined more
    readily.
  • A plan of action or follow-up recommendations
    complete the office visit note.

45
Office Workflow
  • One of the greatest benefits of the EMR is
  • to facilitate office workflow.
  • Intra-office messaging,
  • responding to patient phone calls or e-mail
    messages, and
  • providing medication refills are all part of the
    daily office workload.

46
  • Even though the average family physician may see
    25 to 30 patients face-to-face in the office each
    day, an additional 75 to 100 interact with the
    office through some other means-phone, fax, or
    e-mail.

47
  • They may call for advice about
  • minor problems,
  • prescription refills, or
  • referrals to other providers.
  • In a paper-only system, each of these 100
    interactions requires a special clerk to
    manually do all this work.

48
  • The EMR allows any member of the care team to
    access the medical record at any time, regardless
    of location. Most systems allow multiple users to
    access the same patient's chart at the same time.

49
  • This capability is essential for efficient time
    management and to reduce waiting times and
    delays. The ability to access patient records
    from remote sites is especially important for
    physicain groups with multiple practice sites and
    for physicians who are on call while at home or
    at the hospital.

50
STANDARDS
  • Most office-based health information technology
    in use today, including the EMR, cannot be used
    to exchange much information with laboratories,
    pharmacies, or patients and family members.
    Connectivity between the practice EMR and these
    important sources of information within and
    outside the office practice environment is
    necessary to prevent computerized systems from
    becoming data islands.
  •  
  •  

51
  • A growing number of data content, format,
    vocabulary, and messaging standards play an
    important role in health IT adoption. Perhaps the
    most significant to family physicians is the new
    interoperability standard called the Continuity
    of Care Record (CCR).

52
  • The CCR is not an electronic health record but
    rather a snapshot of the information the medical
    record contains at a given point in time. The CCR
    is compatible with other efforts to standardize
    health information systems and can work in
    conjunction with these efforts.

53
  • The CCR is a document standard for basic
    health information that uses XML (extensible
    markup language). The CCR is intended
  • to foster continuity of patient care,
  • to reduce medical errors,
  • and to increase patients' role in managing their
    own health care.
  • It will also enable epidemic monitoring, public
    health research,
  • and ensure at least a minimum standard of secure
    health information transportability.

54
  • Utilizing Technology in health care facilities is
    no longer the future.

IT is TODAY!!!
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