medical documentation issues and hurdles
TRANSCRIPT
![Page 1: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/1.jpg)
Medical Documentation Issues and Hurdles
Dr. Sameer VankarSenior Resident
Emergency MedicineJPNATC,AIIMS,New Delhi
![Page 2: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/2.jpg)
Medical Record Papers
• Disadvantages: Documentation issues Organizational issues-Storage & Retrieval Wear and Tear
![Page 3: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/3.jpg)
Documentation issues
![Page 4: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/4.jpg)
Storage
![Page 5: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/5.jpg)
Wear & Tear
![Page 6: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/6.jpg)
EMR
An electronic medical record (EMR) is a computerized
medical record created in an organization that delivers
care, such as a hospital
![Page 7: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/7.jpg)
![Page 8: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/8.jpg)
![Page 9: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/9.jpg)
![Page 10: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/10.jpg)
![Page 11: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/11.jpg)
11
Patient’s entire health record
Cover Page Areas
Menu Bar
View or add current problems
Lab reports
Hospital visit data
![Page 12: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/12.jpg)
METHODOLOGY
• Study design- Qualitative survey • Performance centre - ED of JPN Apex Trauma
Centre, AIIMS• Study duration-February to October 2010 (3 surveys)• Study Group-22 Emergency Care Providers
Doctors 8
Nurses 14
Total 22
![Page 13: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/13.jpg)
Study Tool
Structured, closed ended questionnaire consisted of 12 questions based on:
Usability
Applicability
Security
Helpful in research of EMR
![Page 14: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/14.jpg)
Question Are you aware of CPRS (computerized patient record system)? a) Yes b) No If your answer to the above question is ‘Yes’ please proceed below:
Usability: 1. Do you have problem in logging into CPRS? a) Never b) Sometimes c) Very often d) Always 2. Overall, how easy is the computerized MLC form? a) Not at all b) To some extent c) easy d) Very useful
3. Overall, how easy is the computerized transfer notes? a) Not at all b) To some extent c) easy d) Very easy
4. Overall, how easy is the computerized discharge summary? a) Not at all b) To some extent c) easy d) Very easy
5. Overall, how easy is the computerized entry of patient vitals? a) Not at all b) To some extent c) easy d) Very easy
Applicability:
6. Do you think this system is helpful in overall patient care? a) Never b) Sometimes c) Very often d) Always
7. Do you feel demographics are more accurately entered in all forms (MLC form, transfer out forms, discharge summary) by using the computerized system? a) Never b) Sometimes c) Very often d) Always
8. Do you think computerized MLC form is helpful for police and judiciary (courts)? a) Never b) Sometimes c) Very often d) Always
Security:
10. Do you think data can be manipulated in system (after sign off)? a) Never b) Sometimes c) Very often d) Always
11. Do you think this system will help in improving transparency and accountability? a) Never b) Sometimes c) Very often d) Always
Research: 12. Do you feel this system can be helpful in research? a) Never b) Sometimes c) Very often d) Always
![Page 15: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/15.jpg)
METHODOLOGY (CONTD.)
• Likert scale (LS) was used (Likert 1=worst, likert 4=best)
• Surveys were done on day- 20 ,
day- 45 day and
9 months of implementation of EMR
• Response of emergency care providers (ECP) were compiled
• Data analyzed by SPSS version 16
![Page 16: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/16.jpg)
Result
log
in p
robl
em
ease
of c
ompu
teriz
ed M
LC
ease
of e
lect
roni
c tra
nsfe
r not
es
elec
troni
c di
scha
rge
sum
mer
ies
vita
l ent
ry
help
ful i
n pa
tient
car
e
dem
ogra
phics a
ccur
acy
appl
icabi
lity
of e
lect
roni
c MLC
form
man
ipul
atio
n of
dat
a
trans
pare
ncy
and
acco
unta
bilit
y
rese
arch
0
0.5
1
1.5
2
2.5
3
3.5
4
2.23
2.5 2.45 2.41
2.71 2.72
32.82
1.41
2.77
3.32S1 S2 S3
![Page 17: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/17.jpg)
Hurdles
![Page 18: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/18.jpg)
Hurdles
![Page 19: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/19.jpg)
Hurdles
![Page 20: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/20.jpg)
Hurdles
![Page 21: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/21.jpg)
Advantages
• Relatively complete• Tamper proof• Learning• Research• Easy retrieval
![Page 22: Medical documentation issues and hurdles](https://reader036.vdocuments.mx/reader036/viewer/2022062312/556b03c2d8b42a2a4f8b5215/html5/thumbnails/22.jpg)