Professional Documents
Culture Documents
Records
A record is a group of separate related data fields/elements that form a single unit information. A record may be of fixed length or variable length, depending on the computer and the method and type of storage media. A fixed-length record allows a fixed number of spaces for a field or data element; a variable-length record takes only the spaces it actually needs.
Fixed-length record Not flexible Not efficient Programs to process them are easier to be prepared Cost less
Variable-length record Flexible Store data more efficiently Difficult to prepare computer programs using them Cost more
Patient Record
The patient record is the major document that contains data about the patients health care. It is used by all the providers of health care services to record, store, and review information.
make available information about the patient make available information to the patient protect the patient rights regarding their clinical and personal information
Professional purposes
improve the capacities to reach a diagnosis, to state a prognosis and to prescribe an adequate therapy provide a legal context for the collection of the data enable each care provider to authenticate their entry by signature
Ethical purposes serve the needs of the ethical context provide data which is sufficient for the purpose
provide information about the disease episode provide a means for cumulative information about specific diseases and programmes aid in the optimisation of technologies for care
Training purposes
CEN/TC251/PT011/N300/V.1.00
Patient purposes For the diagnosis, prognosis, treatment and follow-up of the patient For planning and defining the care for the patient To ensure continuity of disease prevention and diagnosis, prognosis, and treatment
Professional purposes As a diary for the providers of care For protection of professionals For audit of the providing of care/quality control For efficient and effective providing of care For day to day management of the care system Management purposes For providing the best quality of care As a basis for measuring resource use by the patient For billing when required For planning of the care system Statistics and Research purposes For statistics/research at any level in the care system Training purposes For trainining or updating clinical skills Third-party financial purposes To meet the requirements of Insurance companies who are partly or completely paying for care To meet the requirements of Communes and Government organisations paying for care To meet the requirements for audit of the care system at any level
Data structures
A structure of only one record item complex Tree structure (a data structure composed solely of original record item complexes and a query record item complexes Directed acylic graph structure (the structural links of the View record item complexes extend the pure tree structure into a directed graph structure)
Record item
A record item is a construct that shall be used for the representation of a healthcare record entry or a component of a healthcare record entry where all such components are regarded as constituting meaningful quantities of information when considered alone. A record item shall be composed of a set of attributes that expresses some characteristics of the item. CEN/TC 251/PT 011/N 300 V.1.00
Diagnosis: Fracture of the femur Family history: Both parents died from myocardial infarction Patient history: Fell on slippery pavement in Oslo yesterday Status: Examination of the right leg shows.etc.
A defined set of records, e.g. the set of records belonging to an electronic healthcare record system, may be regarded as a record item complex. A record item complex shall be composed of a set of attributes that expresses some characteristics of the record item complex.
City HC
Jane Smith
561224-1234 #2
Careplan #1
Fracture of femur:
931212 pH
Diagnosis: Fracture of the femur Family history: Both parents died from myocardial infarction Patient history: Fell on slippery pavement in Oslo yesterday Status: Examination of the right leg shows.etc.
Nursing Difficulties managing activities of daily living Problems Anxiety for her heart
Fear for how to manage home
Goals
In three weeks Mrs Smith is able to take care of daily activities With professional help Mrs. Smith can recover whithout fear for her heart
Home health care nurse helps Mrs. Smith in the Interventions first days 2 hours mornings and evenings using: - Activity therapy - Emotional support - Rehabilitation exercises - Self care assistance - Training activities in daily living
Medical Record
Nursing Record
931212 pH
Diagnosis: Fracture of the femur Family history: Both parents died from myocardial infarction Patient history: Fell on slippery pavement in Oslo yesterday Status: Examination of the right leg shows.etc.
The set of items that, for some reason, is regarded as constituting a unit in a particular HR, is called a Healthcare record item complex.
Conceptual models
(1)
To make possible the improvement of health care quality and the better use of resources To facilate the conformance of HRs to the ethico-legal practices and other policies applicable To facilitate safe understandable communication between different electronic healthcare record systems and with other computer-based systems in the healthcare environment used for other purposes To facilitate safe understandable communication between electronic healthcare record systems and healthcare professionals To facilitate the changing of electronic healthcare record systems while keeping the data To promote competition between systems vendors and between health care providers To promote open systems, based on common components, data output, interfaces, structure and data access To improve productivity of the Information Technology industry and quality of the software, and enlarge the healthcare software market To facilitate the free movement of patients by improving the portability of the healthcare record To promote the use of common conceptual models, terminology and definitions. Thus, the architecture must...
(2)
be compliant with other architectures within the healthcare framework promote healthcare records suitable for the clinical purposes in a closed or open clinical environment for private or public systems of care facilitate inter-working among various healthcare enterprises for the benefit of the patient increase the security and safety of operations on the information in the record (both for the person in question and for the healthcare professionals) satisfy the domain requirements of the healthcare professionals permit the representation of different kinds of content, including text, coded information, images, graphics and sound enable the representation of context information enable the healthcare record to operate in theappropriate ethico-legal environment enable the operations on the record to be audited by the person in question, by the user of the record or by a competent third party, if required enable each entry, decision, prescription or any other order to be appropriately signed by each legal responsible person, if required facilitate the convergence of different terminology facilitate new functions of healthcare record systems, adapted to clinical circumstances, management requirements, system needs, and advancing technology facilitate the interchange of records facilitate the tracking of the assembly of a healthcare record and its sub-components during active use ensure that the archived record is a safe and proper assembly of its components and subcomponents provide a means for the safe control of copying one or more sections of the record and for regulation of the lifetime of those topics
Inaccessibility (one user, one location often Decentralised, simultaneous access all the time not always in the same place), parts of the records are geographically distributed Passive: unable to trigger certain actions Active: it can trigger certain actions according to data Non-standardised information handling Standardised information storage, increasing legibility; it allows communication between departmental systems and can lead to an improvement of quality assurance Manual linkage Increased linkage with external health care providers More risks of being incomplete (by lending, Can improve completeness by additional checking less control of completeness) mechanisms at data entry No flexible data representation (one Flexible representation of data following various views representation only) tailored to the needs Time consuming to explore for clinical or Excellent basis to conduct clinical and financial studies financial studies No risk of technical failure Risk of technical failure and unavailability depending on the hardware/software Lower cost(only entry cost not overall cost) Higher cost for installation, training and management of the system Enter handwritten data manually Probable resistance and fear of entering data into the computer Protection and confidentiality; easy to Protection and confidentiality more dificult to maintain access