Patient medical record information

Information required in patient medication records includes name, age and gender of the patient, diagnosis, current medication therapies, and medication allergies. 

Mrs PG, mother of 10-year-old Tanya, came into the pharmacy a few days ago with a prescription for her daughter. The prescription requested penicillin V oral solution 250 mg/5 mL, 250 mg four times a day and flucloxacillin syrup 125 mg/5 mL, 125 mg four times a day, at least 30 minutes before food. Her mother requests information on her daughter s condition, cellulitis. You notice from your patient medication records that Tanya had recently been treated for athlete s foot. 

The medical record is another source of medication and health-related information. Access to this record may be limited in certain practice settings however, it can be a valuable tool to review prior to conducting your patient drug history interview. Some practitioners use medical release forms to obtain medical record information such as laboratory data from other institutions required for drug therapy monitoring. 

While the SOAP approach is very practical and systematic, it may not be appropriate for many pharmacists because there are limitations with respect to consistent access to certain data elements available in many practice settings. Additional concerns relate to the redundancy created in a patient record if the pharmacy documentation is to become part of an existing record. Such patient medical records are already voluminous, and only succinct, essential information needs to be added. Thus the contributions of pharmacist-generated documentation should be supportive of a patient s care plan to assist in achieving defined therapeutic objectives and/or avoiding drug-related problems (DRPs) where appropriate."... 

After the 1970s, computers were routinely applied to study and design molecules and increasingly those molecules of importance to the pharmaceutical industry. Eli Lilly, for example, increased the value of its stock by purchasing a Cray supercomputer. Computers in the late twentieth century were also used in medical record keeping, though the full actual patient medical record itself was rarely kept on the computer except the information required for billing. 

Limited Knowledge of Exposure and Reporting Rates in Postmarketing Data. Unlike clinical trials and electronic medical records in clinical practice, postmarketing voluntarily reported data contain limited information about the total number of patients exposed and the duration of exposure. This problem is compounded by the fact that adverse events are often underreported [2,9]. 

The physical examination should be performed rapidly and efficiently, with efforts directed toward uncovering the most likely cause of sepsis. The patient may or may not provide any medical history therefore historical data may be obtained from medical records and/or family. The patient s medical condition, recent illnesses, infections, or activities may provide valuable information about the cause of sepsis. 

Medical Records Recording of pertinent information concerning patient s illness or illnesses. [NIH]... 

Complete access to the patient s medical information (i.e., the medical record)... 

An essential element of any medical program is informed patient consent prior to the performance of any test or procedure. Although informed consent is not specifically mentioned in the ACOEM components of occupational and environmental health programs, it is inherent in the ethical practice of medicine. The ACOEM Code of Ethical Conduct (adopted October 25,1993) states that physicians should relate honestly and ethically in all professional relationships. Also, the Association of Occupational and Environmental Clinics has issued guidance relative to patient consent, confidentiality of medical records, and communication of the results of tests and procedures (AOEC, 1987). 

The board would review the project using the following four criteria that were developed to protect individuals privacy interests for research using existing medical records (1) Would the research be impracticable without the information (2) Is the research important enough to outweigh the intrusion into patient privacy (3) Is there an adequate plan to protect identifying information from improper use and disclosure and (4) Is there an adequate plan to destroy the identifiers at the earliest opportunity [45 C.F.R. 163.510(j)]. 

The guideline specifically states that an explanation of the subject s responsibilities must be referenced during the informed consent discussion and included in the consent form and any other written information. Also, the person responsible for conducting the informed consent discussion is required to sign and date the informed consent. The document must specify the parties granted direct access to the patient s original medical records. 

For professionals who work in the same setting, the rules around confidentiality are less clear, particularly when patient charts contain both medical and mental health notes. Treatment teams in the same setting could assume that a free exchange of information is allowed and necessary. We agree, but we also believe that making this policy explicit to the patient and family is important. Case notes are especially vulnerable to mishandling. For example, there is always a chance that mental health notes that are part of the medical record could be unintentionally released to a third party. If expectations are communicated and understood among the patient, family, therapist, and physicians, confidentiality need not impede collaboration (see Tables 10.3 and 10.4). Furthermore, collaboration need not violate confidentiality. 

The two aspects of documentation are documenting care delivered to patients and documenting progress toward meeting practice plan objectives. The problem-oriented medical record is used by health care professionals to convey information about patient care. The problem-oriented medical record is a means to organize observations into a systematic, problem-solving approach that can be conveyed to others. The problem-oriented approach to documentation is intended to streamline the amount of reading that practitioners must do to update themselves on a patient s status. 

Electronic Diary Cards are portable, hand-held systems designed to be programmed according to specific protocol requirements and are used by patients to record directly information on their condition and medication consumption during a particular study. They should be specified and designed so that they are highly prescriptive since they are used in a relatively uncontrolled environment (e.g., subject s home). Specific considerations for the validation of electronic diary cards are ... 

Most analytical devices used in clinical laboratories are directly linked or connected via an electronic interface to a laboratory information system (LIS). In this progression, many different informatic functions (see Chapter 18) are used, including the electronic transfer of data from the analyzers to the LIS and ultimately into a patient s electronic medical record. This provides healthcare professionals with quick, accurate, and appropriate access to the patient s medical history and information. 

Information systems are often described in terms of the entities about which they manage information, the attributes that describe those entities, and the relationships between the entities. This approach to modeling the information is called entity-relationship modeling or E-R modeling. Patients, providers, specimens, and orders are examples of entities, and medical record number, provider identifier, accession number, and order number are all examples of attributes. The relationship between these entities is represented by a data structure that includes a particular patient identifica-... 

The immediate resolution to these issues is to ensure that the complete medical record is secured and that hospital employees and others access only information that is needed for patient care. All employees should be made aware of policies related to confidentiality of patient records and the importance of adhering to principles of patient privacy In... 

---