Integrated medical record

The concept of an integrated medical record (from womb to tomb) or heterogeneous archival life object (HALO), shown in the Figure 5.1, goes back... 

Figure 5.1 Heterogeneous archival life object (HALO) as a type of integrated medical record (IMR)...

The Drug Information Centre should always be available by telephone, but can also answer inquiries by mail, e-mail, Internet based formularies or by functions integrated into local technical systems, such as computerised medical records. 

Presence of an integrated electronic medical records system. 

It may be mission critical to the profession for pharmacists to gain or maintain read/write privileges where all pharmaceutical care contributions can be viewed by all caregivers. Additionally, pharmacists will need to be able to access diagnosis, laboratory, and other charted information such as demographics on a common medical record. Thus, at a minimum, it will be necessary for all pharmacy software to be able to be integrated into the electronic medical records as they emerge. 

In conjunction with other members of the home care team and with the patient s physician, a decision is made to either accept the patient for home care services or refer them back to the hospital discharge planner or referral source. Once accepted, an assessment is completed and an initial patient database established. Table 2 lists some of the items that are part of this database. Again, the pharmacist is an integral part of this process. Much of this information is obtained via the telephone in conversations with the physician, hospital personnel, or patient. Information may also be received via fax or from the home care agency nurse. Pharmacists working in a hospital-based home care pharmacy may be able to go up to the floor and obtain this information directly from the medical record, floor nurse, and/or patient. 

TGL is an industry partner in a major research project, which provides one postdoctoral and two doctoral scholarships to further develop and optimize the production of electronic Therapeutic Guidelines, including the integration of Therapeutic Guidelines with prescribing, dispensing, and medical record management software. 

Following an occupational exposure, it is vital that healthcare workers are cognizant of institutional policies and procedures to allow for the timely and organized collection of data and initiation of post-exposure prophylaxis if indicated. Institutions must have policies and procedures in place to react quickly to occupational exposure to avoid unnecessary delays in therapy. The date and time, details pertaining to the type of activity being performed, nature of the exposure (type, amount, severity, percutaneous, mucous membrane, time of contact, condition of skin), and details about the source (HIV infected, viral load, history of antiretroviral therapy) should be recorded in the healthcare worker s medical record. It is recommended that skin sites or wounds that are contaminated should be washed with soap and water. The use of antiseptics may be considered, but application of caustic substances such as bleach is not recommended, as this would compromise the integrity of the skin barrier. Mucous membranes should be flushed extensively with water. 

J. D. Halamka, C. Osterland, and C. Safran. 1999. Care Web, a web-based medical record for an integrated health care delivery system. International Journal of Medical Informatics 54 1-8. 

Integrating Image Viewing into the Electronic Medical Record... 

More efficient integration of device-generated data into electronic medical record (EMR) systems... 

Make certain that proper wiring/cabling is included in all non-traditional areas where medication may be dispensed or delivered technology applications such as pharmacy decision support, bar-coding, computerized physician order entry (CPOB), or elearonic medical records (EMR) should be integrated with appliances such as IV pumps. 

L. Liu and D. Zhu, "An integrated e-service model for electronic medical records," Information Systems and e-Business Management, vol. 11, pp. 161-183,2013. 

Personal health record A PHR is also called a personally controlled health record (PCHR), or a personal electronic health record (PEHR), among others. This is a record of health owned and maintained by an individual—the emphasis on ownership and maintenance is important. Strictly speaking, PHRs do not include records owned or maintained by healthcare workers—those are called electronic medical records (EMRs) or electronic health records (EHRs). The distinction is sometimes blurred, as in cases of EMRs or EHRs to which the patients have access—those may be called integrated PHRs or tethered PHRs [1]. Also, PHRs are certainly not restricted to "patients," individuals who at the time are ill instead, PHRs are records of health maintained by mostly healthy, but sometimes ill, people. PHRs should contain the following ... 

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