No abstract available.
Medical Records

No abstract available.
Humans ; Medical Records

OBJECTIVE: The study reports the clinical outcomes and complication rates of microsurgical clipping of unruptured paraclinoid aneurysms. METHODS: From July 1997 to December 2008, 61 patients underwent microsurgical clipping for 61 unruptured paraclinoid aneurysms in our institute. Entire medical records, radiographic data, and operation records were reviewed retrospectively. RESULTS: After the microsurgical clipping, complete obstruction was achieved in 56 patients (91.8%). Visual disturbance (nine cases, 14.8%) was the most frequent complication. Overall, 59 patients (96.7%) had a good long-term outcome (Glasgow outcome scale score of 4-5 3 months post-operatively). CONCLUSION: For patients with paraclinoid aneurysms, satisfactory outcomes can be achieved by microneurosurgical management. These results will be useful when considering treatment of an unruptured paraclinoid aneurysm.
Aneurysm ; Humans ; Medical Records

OBJECTIVE: The aim of this study was to estimate the feasibility, safety and surgical outcomes of single port access laparoscopic myomectomy (SPA-M). METHODS: We reviewed the medical records of 29 patients with uterine leiomyoma who underwent SPA-M in Gumi CHA hospital between March 2010 and August 2010. We performed SPA-M with conventional rigid straight laparoscopic instruments in all cases. RESULTS: In this study, the mean of leiomyoma weight, operating time, and estimated blood loss were 55.43 gm(+/-54.79, range 5~220 gm), 69.68 min (+/-32.99, range 20~120 min.), 100 mL (+/-104.26 range minimal~300 mL), respectively. Transfusion was done in the one case. CONCLUSION: SPA-M using conventional rigid straight laparoscopic instruments was feasible and could be an alternative to conventional multi-port access laparoscopic myomectomy (MPA-M).
Humans ; Leiomyoma ; Medical Records

Whitnall's ligament plays an important role as a check ligament of the levator muscle and indicates a definite landmark during the procedure of external levator resection. Whitnall's ligament was variable in the level of the ligament. the tightness and appearance etc. The medical records of 193 patients(263 eyes) with ptosis who had undergone levator resection were reviewed from July, 1987 through October, 1994 at Yeungnam University Hospital. The structure of Whitnall's ligament was studied by measurement of the level, gross appearance of the ligament and the tightness. The level of the ligament was the length from the insertion of the levator aponeurosis to Whitnall's ligament. The most common level(88.6%) of the ligament was between 18 mm and 26 mm(range, from 9 mm to 33 mm). Whitnall's ligament levels in mild ptosis with good levator function were higher than in those of severe ptosis with poor levator function. Whitnall's ligament showed gradually higher in level as patients became older. Weak Whitnall's ligament was observed in 21 eyes and more common in mild ptosis.
Humans ; Ligaments* ; Medical Records

Shunt infection remains one of the most frequent and disabling neurosurgical complications. We reviewed the medical records of 40 patients who between 1989 and 1997 underwent CSF shunt surgery involving a total of 48 procedures. Infection occured in six of the 40 patients and secondary postoperative infection in two; i.e. in eight of 48 procedures(16.7%); the microorganisms involved were not always isolated, though in all cases, clinical symptoms were detected. Most episodes occured within 6 months of the last shunt operation and patients under one year old are greater risk of infection than those who are older. To prevent such infection careful preoperative surgical planning is mandatory.
Humans ; Hydrocephalus* ; Medical Records

BACKGROUND

Medical records provide a repository of patient information, physical examination, laboratory findings, and the outcomes of interventions. The completeness of data contained in the electronic medical record (EMR) is an important factor leading to health service improvement. Quality assurance (QA) activities have been utilized to improve documentation in electronic medical records.

To determine the effectiveness of QA interventions (feedback, workshop, and random monitoring system) in improving completeness of data entries in the EMR of resident physicians for COVID-19 teleconsultations.

This was a before-and-after study involving EMR entries of physician trainees on health care workers (HCWs) from March to October 2022 of the COVID-19 pandemic. A chart audit was conducted against a checklist of criteria for three months before and after the interventions. QA interventions included the provision of feedback on the results of the initial chart review; conducting a QA workshop on setting of standards, chart audit, data encoding, analysis, and presentation; and random monitoring/feedback of resident charting. The change in the level of completeness from pre- to post-intervention was computed, and the percentage of charts meeting the minimum standard of 90% completeness was likewise determined.

A total of 362 and 591 chart entries were audited before and after the interventions. The average percentage of completeness of medical records during initial consultation improved from 83% to 95% (p>0.05). The documentation of the reason for seeking consultation significantly increased from < 1% to 84%. The reporting of past exposure and level of risk decreased to 89% (p=0.001) in the initial consult and 12% (p=0.001) in the fit-to-work, respectively. Majority of the criteria for work clearance improved after the intervention. However, the average completeness of entries did not reach 90% post-intervention for fit-to-work consultations.

Feedback, quality assurance workshop, and random monitoring of electronic medical records are effective in increasing documentation practices for the chief complaint and dates of illness duration but showed non-significant increasing trend on overall percentage of EMR completeness for COVID-19 teleconsultations.

OBJECTIVES: Clinical documents (CDs) have evolved from traditional paper documents containing narrative text information into the electronic record sheets composed of itemized records, where each record is expressed as an item with a specific value. We defined medical record (MR) items to be information entities with a specific value. These entities were then used to compile form-based clinical documents as part of an electronic health record system (EHR-s). METHODS: We took a reusable bottom-up developmental approach for the MR items, which provided three things: efficient incorporation of the local needs and requirements of the medical professionals from various departments in the hospital, comprehensive inclusion of the essential concepts of the basic elements required in clinical documents, and the provision of a structured means for meaningful data entry and retrieval. This paper delineates our experiences in developing and managing medical records at a large tertiary university hospital in Korea. RESULTS: We collected 63,232 MR items from paper records scanned into 962 CDs. The MR item database was constructed using 13,287 MR items after removing redundant items. During the first year of service users requested changes to be made to 235 (1.8%) attributes of the MR items and also requested the additional 9,572 new MR items. In the second year, the attributes of 70 (0.5%) of the existing MR items were changed and 3,704 new items were added. The number of registered MR items increased by 72.0% in the first year and 27.9% in the second year. CONCLUSIONS: The MR item concept provides an easier and more structured means of data entry within an EHR-s. By using these MR items, various kinds of clinical documents can be easily constructed and allows for medical information to be reused and retrieved as data. The success of the use of MR items in a large tertiary university hospital system provides evidence that verifies our approach as being an efficient means of user-oriented and structured data entry, enabling the easy reuse of medical records.
Electronic Health Records ; Electronics ; Electrons ; Medical Records

Electronic Health Records ; Humans ; Medical Records ; Odontodysplasia

This research investigated on the medical recorder manpower relation by before / after medical record computerization for the object of 51 hospitals in 1998 year. Judging from the situation before / after computerization shown on this investigation, the number of personnels was more increased since computer work than manual work, and the medical recorder present conditions by years show that they have been gradually increasing. This is considered why affairs diversely change according to computerization, the auxiliary recorder present conditions shows the reduction of 98 year in comparison with 94 year. This is regarded that personnels were reduced by facilities like existing transporting pipes. Accordingly, vast data are produced and utilized in the medical record department(room) too, therefore information will be quickly / correctly dealt for this. The times invested for simple affairs will be easily diminished by making existing simple affairs be computerized, and so personnels will have to be invested to earnestly / diversely utilize vast information not to reduce personnels in proportion to diminished times.
Humans ; Medical Record Administrators* ; Medical Records*