COMPUTERIZED CLINICAL RECORD FILES
The computerization of medical history (HC) has become, in recent years, the objective of most of the work of Medical Informatics.
The replacement of the traditional HC, on paper, by a computerized medical history (HCI), responds to several needs:
1.- Solve the two classic problems of HC files
- The continued growth of stored volume, which creates serious problems of physical space, and
- The inevitable transfer of original documents, with risk of loss and deterioration.
2 .- Allow the rapid transfer of existing health information of a patient to distant points, thus unifying, in fact, the HC above the limits of healthcare institutions.
3.- Make this information available to researchers and health planners, in an easily accessible and treatable form.
What is the Clinical History?
It is the key element for the professional practice of health personnel, both from the point of view of care – it acts as a reminder for the clinical management of the patient – and from the researcher and teacher, allowing the retrospective analysis of the professional work of health professionals.
It can be defined as a document that collects the information that comes from the clinical practice relative to a patient and summarizes all the processes to which it has been submitted.
In the old days, when there were hardly any hospitals and the OBGYN doctor attended individually to all the patient’s needs, his medical records were like a notebook where the most important data was recorded according to his criteria.
When specialization, teamwork and hospital medicine appear, the clinical history became the shared responsibility of a group of professionals. This forced the structuring of the information in a coordinated way.
Despite the high value it has in all aspects (health, legal, educational, research, etc.), there are not too many legal provisions on the obligatoriness of its existence, the documents that compose it and its structure.
And of the different ways that you can order the documents of a story, homogeneously for the whole hospital, usually the chronological by episodes is the most used. In it are grouped the documents separating the information of the episodes of admission (from the date of admission to the hospital until the date of discharge), the documentation of the consultation episodes.
The best: every patient has a single history number
If the story is unique for each patient in a hospital and its management is centralized from a single file, it is guaranteed that all successive episodes of that patient are preserved together.
Obviously, if these conditions are met, the subsequent retrieval of data is facilitated and is much safer and simpler than if the same patient had several histories of different episodes stored in different smaller files in various clinical services of the hospital, since they would be uncontrolled And uncoordinated.
Each patient has a unique reference number, which allows him to hang all the care records that are provided: surgical schedules, appointments in consultations, waiting lists, hospitalizations, emergencies, etc. All data are simultaneously recorded with their history number.
It is something like the current account of the bank, from which we can ask at any time for an extract and see all the movements that have had, and broken down by concepts. Here something similar happens, having the possibility to consult the database of all the assistance practiced to the holder of that history number.
Computerization is not the same as scanning
What do we understand by computerized medical history? For the one in which the information is captured in a mechanized way, that is, you do not use paper and pen to write, but are recorded by a computer keyboard.
A more technical definition would be a global and structured set of information, in relation to medical-healthcare of an individual patient, whose support allows it to be stored, processed and transmitted through computer systems.
Instead, if we decide to digitize the documents of the stories, the information is like a photo (facsimile) of the original and is as passive as the paper support from which it comes. It is nothing more than an emulation of the medical history on paper. The documents are digitized, but the data is still captured in a traditional way, on paper.
Unlike structured information, it does not allow automatic validation, query formulation, statistical processing, program utilization to aid clinical decision-making or quality control. Therefore it must be associated with other auxiliary information, redundant, that acts as an index (an example may be bar code labels to be able to retrieve a document).
In every medical institution, the Clinical History is the most important file, it contains vital information for medical, administrative and legal management. It is the most important module of the system, since all the others are referring to the registers that it manages. It may or may not be present in the system, but its bases must be installed so that the other modules can work.
The basic clinical history can be integrated modules of different specialties such as laboratory and complementary studies to which you can add story models of different specialties and specific studies according to the needs of each user.
It is a system for storing patient data in the clinic (clinics, hospitals), easy to use. It allows the accomplishment of the Clinical History in an orderly way, the codification of the pathologies according to the classification of the WHO and the accomplishment of statistics. See WHO international classification of diseases .
It is unimaginable a current medical institution lacking a centralized information file such as the Clinical History as we know it, where the importation on each patient is distributed in several separate reports generated by each service and department involved, and in the minds of each one Of the doctors and paramedics in charge of the care of the patient in question. Access to the total accumulated information from a newly incorporated physician would be a real feat. The overcoming of this problem undoubtedly constitutes the justified and definitive triumph of the concept of clinical history as a fundamental tool of medical care,
The progressive accumulation of knowledge determines the arrival of a growing number of technicians and specialists who, sometimes without seeing the face at any time, collaborate in the care of the same patient. In these cases, the Clinical History becomes the only means of communication between each of the members of this virtual team. Although the computerization of the CLINICAL HISTORY does not solve, on its own, the whole problem of the management of hospital information, in many cases it offers alternatives that allow to reduce them in its expression or consequences, which makes its implementation desirable.
The HISTORY CLINICAL system allows the storage of:
- A large volume of information, depending on the capacity of the hard disk that is used and access this data by different routes.
- Maintain the updating of the clinical histories in a neat way, as well as the inter-consultations, complementary studies.
- Compatibility with later versions and with accessory programs.
- Integration with billing system, shift reservation, pharmacy, laboratory and complementary studies.
You can search by several items:
- Last name and name;
- Document number;
- Social work number.
It provides the identification of groups of patients by different fields and statistics of the same: Social work; Pathology; Family and media history, etc.
Search and assign the base postal codes to the address of the patient in Capital and Provinces of the Argentine Republic, automatically. Controls the coded input of data, so that you can then correctly perform the statistics. It allows the automatic identification of several diagnoses based on the data we collect in history thus avoiding that personal distractions go unnoticed (in permanent development). Integration with Agenda, Billing and Vademecum system.
Control of the users of the system by means of Password and their work levels.
It has a vade mecum incorporated into this system. This allows checking the medication with the data collected in the Clinical History automatically, warning the doctor about possible contraindications or drug interactions.
To the main menu, which we access after having identified us as users. As we see in the same figure we have different options available we will pass next to describe the same ones. Patient data
can be searched for several items, according to the option we choose: Last Name and First Name: It is not necessary to fully type the last name or the name, with the first few letters is enough, if there are several that start from the Same way the options will be displayed on the screen and then you can select the one you want to examine.
In the Personal Data screen , the Clinical History number can be entered in different ways or the system assigns it automatically. It is important to emphasize that this number is the one that relates all the databases of the system that store patient information. For this reason the modification operation is a delicate task that is reserved for high level users.
The system is multi-dossier, that is, the same clinical history can be divided into several dossiers (x-rays, ultrasound, dossier, etc.). The processes related to files (petitions, loans, etc.) are made on the dossier and not on the medical history, although it allows a process to be applied to all dossiers in a medical history.
Thus, you can request, lend and return a portion of the medical record. Each of them will have a location and a state, at a given time.
The system maintains a list of defaulters: a receiver of a history becomes part of the list of delinquents as soon as the date foreseen for the return of the file (s) is exceeded without being returned.
The system allows the search of a dossier indicating its current situation (borrowed, filed, lost) and the date from which it is in that situation.
It is also possible to consult the loan history of a file.
SEARCH OR IDENTIFICATION OF GROUPS
The System provides the identification of groups of patients by different fields and statistics of the same: Social Work; Pathology; Family and media history, etc.
To use these options we must refer to the statistics module or the list module.
Along with the program in the same subdirectory there is a program called useful through which you can run some utilities that are not provided in this module built into the program.
This module allows to carry out a series of statistical studies of fields pre-selected for this purpose. It gives information about the total and the respective percentages of each item. The analysis of the data is performed in memory so it will be limited to this data vector that can be loaded. For analysis of more data, use the Statistical accessory module.
Make the list of patients sorted by Last Name and First Name.
It contains the data of Surname and Name, Street and number, telephone, Social Work and number of the same, first and last query.
If you want to perform Mailing to Patients you can do it through the agenda module.
The listing can be made under conditions that can be determined by the system user (see instructions below).
Allows the listing of patients by several fields indicating the characteristic of the same.
LOW DATA PROCEDURE
As its name implies, it leaves the patient selected but not in definitive form. In case of accidental download you can recover the deleted file with the utilities menu in the option to recover marked records. This option is only valid if a packet has not been previously made (definite deletion of marked records).
The first data entry screen corresponds to the personal data of the patients . The System provides for measures to control the reservation and security of the data that is stored in the same, security in the information available in the fields memos. The program takes into account the legal aspects of computerized medical records that must be collected by computerized medical records.
REASON FOR CONSULTATION
The provision of the reason for consultation is entered or entered in a coded form, being able to examine the different reasons for consultation that the patient has had during his care for the different services over time. It is recorded who records each reason, date and time and the service and / or sector that registers it.