Topics in health record management
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Top Health Rec Manage · May 1992
Legal review: the medical records implications of state and federal anti-dumping provisions.
Federal and state enforcement agencies have increased their scrutiny of hospitals to make certain they are complying with anti-dumping law. Medical record practitioners can assist their institutions by providing policies that require appropriate documentation of compliance. Given the potential sanctions imposed by anti-dumping laws, these policies should be reviewed carefully by hospital administrative, medical, and legal personnel.
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Top Health Rec Manage · Mar 1992
Bar code tracking system enhances record- and film-handling productivity.
The bar coding system has proven to be highly successful. Use of the bar code label has already been added to the dictation system in medical record and medical imaging services departments for entry of patient identification of each dictated report. Other system enhancements under consideration include tracking ancillary department reports as they are forwarded to the medical record department for storage in the permanent patient record and tracking individual volumes of a patient's medical record.
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Top Health Rec Manage · Nov 1991
Instituting a concurrent process for monitoring the clinical risk of physicians' practice.
By implementing a more concurrent program for identifying and responding to situations that put patients at risk, such as the approach described in this article, hospital quality assurance and risk management professionals, as well as the medical staff and administration, may finally achieve the complementary goals of increasing the quality of clinical care while simultaneously reducing claims and suits against the hospital and its physicians.
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Top Health Rec Manage · Aug 1991
The impact of the HELP computer system on the LDS Hospital paper medical record.
This study sought to answer the question: What percentage of an LDS Hospital patient's chart is contained in the HELP system? Using the number of pages in the record as the criteria, the answer is about 26 percent overall, but between 35 percent and 40 percent for patients in nursing divisions where computerized nurse charting is used. Although this fraction is likely to rise in the near future, the critical factor driving computerization is the desire for data usable in computerized decision making rather than the need to computerize the entire chart per se. The medical record at LDS Hospital will probably be a hybrid of computerized and paper data for some time to come.
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The Pennsylvania Trauma Systems Foundation has existed for five years. A concept that in 1984 seemed like a futuristic dream has been accomplished. Standards for trauma center accreditation have been developed, and trauma centers are accredited in a fair, unbiased, and systematic manner. ⋯ Data collected have been used for quality assurance, the accreditation process, and trauma prevention and research. The commitment by medical record professionals to develop and maintain individual hospital trauma registries as well as the PTSF trauma registry has been enormous. The future of trauma system development in Pennsylvania lies in the data collection system and the research in trauma systems and trauma care that is generated from the database.