Documentation for Health Records

Documentation for Health Records
Author: Cheryl Gregg Fahrenholz,Ruthann Russo
Publsiher: Unknown
Total Pages: 744
Release: 2013-01-01
Genre: Medical
ISBN: 1584262621

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Documentation for Medical Records

Documentation for Medical Records
Author: Barbara Odom-Wesley,Diann Brown,Chris L. Meyers
Publsiher: Unknown
Total Pages: 538
Release: 2008-08
Genre: Medical informatics
ISBN: 1584261838

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The Computer Based Patient Record

The Computer Based Patient Record
Author: Committee on Improving the Patient Record,Institute of Medicine
Publsiher: National Academies Press
Total Pages: 215
Release: 1997-10-28
Genre: Medical
ISBN: 9780309578851

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Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Registries for Evaluating Patient Outcomes

Registries for Evaluating Patient Outcomes
Author: Agency for Healthcare Research and Quality/AHRQ
Publsiher: Government Printing Office
Total Pages: 396
Release: 2014-04-01
Genre: Medical
ISBN: 9781587634338

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This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Secondary Analysis of Electronic Health Records

Secondary Analysis of Electronic Health Records
Author: MIT Critical Data
Publsiher: Springer
Total Pages: 427
Release: 2016-09-09
Genre: Medical
ISBN: 9783319437422

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This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.

Digital Healthcare Empowering Europeans

Digital Healthcare Empowering Europeans
Author: R. Cornet,L. Stoicu-Tivadar,A. Hörbst
Publsiher: IOS Press
Total Pages: 1092
Release: 2015-05-08
Genre: HEALTH & FITNESS
ISBN: 9781614995128

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The digitization of healthcare has become almost ubiquitous in recent years, spreading from healthcare organizations into the homes and personal appliances of practically every citizen. Thanks to the collective efforts of health professionals, patients and care providers as well as systems developers and researchers, the entire population of Europe is able to participate in and enjoy the benefits of digitized health information. This book presents the proceedings of the 26th Medical Informatics in Europe Conference (MIE2015), held in Madrid, Spain, in May 2015. The conference brings together participants who share their latest achievements in biomedical and health Informatics, including the role of the user in digital healthcare, and provides a forum for discussion of the inherent challenges to design and adequately deploy ICT tools, the assessment of health IT interventions, the training of users and the exploitation of available information and knowledge to further the continuous and ubiquitous availability and interoperability of medical information systems. Contributions address methodologies and applications, success stories and lessons learned as well as an overview of on-going projects and directions for the future. The book will be of interest to all those involved in the development, delivery and consumption of health and care information.

Care of the Acutely Ill Adult

Care of the Acutely Ill Adult
Author: Fiona Creed,Christine Spiers
Publsiher: Oxford University Press
Total Pages: 448
Release: 2020-10-08
Genre: Medical
ISBN: 9780192527080

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This key textbook equips all nurses with the knowledge and skills required to care for the deteriorating patient in the clinical environment. The book emphasises the importance of systematic assessment, interpretation of clinical signs of deterioration, and the need to escalate the patient in a timely manner. Using a unique system-based approach, each chapter contains structured learning outcomes and concludes with a competence-based skills assessment to perfect the reader's practice skills. These skills are recommended as essential for every nurse in an acute area and key to successful practice. Restructured for ease of use, this new edition has been fully updated to match current guidelines, with new chapters on pain management and the ethics and ceilings of treatment. Written by senior nurses, this key textbook uses real life case studies to link knowledge to practice and is essential reading for all nurses working in acute care settings and undertaking study in the field.

Healthcare Documentation

Healthcare Documentation
Author: Ellen A. Drake,John H. Dirckx,Sally C. Pitman,Health Professions Institute
Publsiher: Prentice Hall
Total Pages: 0
Release: 2014
Genre: Medical records
ISBN: 0132988143

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Ideal for learners with no prior experience and those seeking refresher training, Healthcare Documentation: Fundamentals and Practice, 4/e is the most comprehensive healthcare documentation learning system available. It begins with a thorough overview of the medicolegal and technology aspects of healthcare documentation, including key trends such as electronic health records, security, privacy, and speech recognition. Next, it provides integrated content linked to 10 hours of authentic medical dictation practice. Extensive exercises in the text combine with online audio exercises to systematically reinforce core knowledge and build critical thinking, editing, and research skills. The final chapter focuses on finding employment and preparing students for the workplace, professional development, and continuing education. This edition has been extensively revised for the latest industry trends and techniques, contains many new learning features, and offers a compelling new full-color design with many new illustrations.