Title: Medical Records in Family Practice
1Medical Records in Family Practice
2(No Transcript)
3Introduction
- 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.
4Important 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.
5Criteria 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.
6Types 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.
72- 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.
113- 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
14For 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.
16- S Cough for 3 days
- O left lung collapse
- A Severe distress due to collapse of
- left lung
- P Immediate referral to chest
- physician
174- 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
18Flow 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
195- 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)
206- 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.
217- 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
22Methods 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 - .
23Electronic 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.
32What 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.
33Many 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 36Medication 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.
40Laboratory 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.
424-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.
45Office 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.
50STANDARDS
- 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!!!