Computer systems and communication technologies made a strong and influential presence in the different fields of medicine. The cornerstone of a functional medical information system is the Electronic Health Records (EHR) management system. Several electronic health records systems were implemented in different states with different clinical data structures that prevent data exchange between sy...

introduction: since hospitals are the main healthcare providers, they are assumed as the main institutions for implementing information systems. hospitals need efficient hospital information system (his) to manage their raising needs. this study reviewed the importance of his, implementation of prerequisites and selection factors from views of staff of medical record department in hospitals aff...

There is growing recognition of the importance and potential benefit of information technology and electronic medical records in providing quality care for women. Incorporation of obstetrician-gynecologist-specific requirements by electronic medical record vendors is essential to achieve appropriate electronic medical record functionality for obstetrician-gynecologists. Obstetricians and gyneco...

BACKGROUND Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an...

We describe the use of clinical data present in the medical record to determine the relevance of research evidence from literature databases. We studied the effect of using automated knowledge approaches as compared to physician’s selection of articles, when using a traditional information retrieval system. Three methods were evaluated. The first method identified terms and their semantics and ...

To accurately support a patient's medical record, at least four interrelated models are required: a simple static one-level schema is inadequate. The models must support the medical record as a coherent story reconstructed from the sequence of recorded events within the medical record. We propose one representation which unifies all four models by a three space approach, each space acting as a ...

Fungal bloodstream infection (BSI) is of increasing concern in the hospital environment. This study compared routine hospital discharge data at two inner Sydney hospitals with a pathology database over a 6-year period. A high level of underreporting was found, with only 42% of the pathology database cases assigned an appropriate code in the hospital discharge data despite evidence of the infect...