The value of a digital management system for the medical records of patients with cerebral hemorrhage.

Objective: The present study aimed to explore the value of a digital management system based on micro digital imaging technology for the medical records of patients with cerebral hemorrhage. Methods: A total of 540 patients with intracerebral hemorrhage diagnosed and treated in the hospital from November 2016 to November 2019 were selected as the subjects of this study. A digital management system based on micro digital imaging technology was used to establish how to handle the medical records of these patients. Results: The medical record management process of patients with cerebral hemorrhage comprises five modules: medical record editing, medical record querying, medical record borrowing management, statistical analysis, and system maintenance. The purpose of these is to manage and store digitalised medical records for patients, present the most useful information on the first page of the medical records, monitor the safety of the medical records, and enable real-time data sharing. Conclusion: Establishing a digital management system based on micro digital imaging technology for the medical records of patients with cerebral hemorrhage can effectively enable the preservation and use of these documents. It improves information management, such as data sharing, security, and the overall level of information. This is worth promoting.

Application of DRGs in hospital medical record management and its impact on service quality.

BACKGROUND: To explore the application of diagnosis-related groups (DRGs) in hospital medical record management and the impact on service quality. OBJECTIVE: This study introduced DGRs management into hospital medical record management in order to improve the quality of hospital medical record management. METHOD: The medical record management of our hospital was analysed retrospectively between August 2020 and April 2021. A total of 7263 cases without DRG management before January 2021 were included in a control group, and 7922 cases with DRG management after January 2021 were included in a study group. The error rate of medical records, the specific error items and the scores of service capability, service efficiency and service quality were compared along with the comprehensive scores of the two groups. RESULTS: The error rate of medical records in the study group was significantly lower than that in the control group (19.35% vs. 31.24%, P < 0.05). The error rates in terms of diagnosis on admission, surgical procedures, main diagnosis and other diagnoses in the study group were significantly lower than those in the control group. The scores for service ability, service efficiency and service quality were significantly higher in the study group than in the control group (P < 0.05). The comprehensive evaluation score of the study group was significantly higher than that of the control group (P < 0.01). CONCLUSION: Applying DRGs in the hospital medical record management can effectively reduce the error rate of medical records and improve the quality of hospital services.

Construction and practice of paperless management in medical records automatic archiving / 中华医院管理杂志

As medical record management is key to hospital management, a hospital introduced paperless practice of automatic archiving in the following practices. Clarification and identification of the scope of business system transformation, establishment of an architecture integrating various business systems, integration platform, hospital data center, archiving system and certification authority, creation of three automatic archiving processes: initial archiving, late return archiving and modification archiving, for refined management of the review and tracking of archived medical records. Thanks to this paperless management, the automatic archiving rate was as high as 95.95%for medical records, 96.47%for laboratory reports and 99.58%for medical orders respectively. A full-process and whole-cycle informationized closed loop management was achieved for the collection, archiving, review and utilization of medical records, substantially upgrading hospital informationization and medical record management.

Practice and Exploration of the Construction of Management System for Off-label Drug Use in Our Hospital / 中国药房

OBJECTIVE： To establish the management system for off-label drug use in a medical institutions， and to standardize the behaviors of off-label drug use and improve the rational drug use. METHODS： Based on evidence-based researches for off-label drug use， management system of off-label drug use was established in our hospital， and off-label drug use management was carried out. The effects of management system were evaluated with the number of records for off-label drug use and pass rate of approval as indexes. RESULTS： Since the year of 2011， the management system for off-label drug use had gradually established and improved in our hospital； the mode of registration and approval for off-label drug use was established by based on a multi-disciplinary team management and quality classification for clinical evidence. Up to 2016， a total of 252 records for off-label use were submitted， among which 159 （accounting for 59.77％） were for pediatrics and 93 （accounting for 34.96％） were for gynecology and obstetrics. Among the submitted records， 181 had passed the examination and approval， and the pass rate was 64.29％. Special prescription comments indicated that the numbers of off-label use medical orders in inpatient medical orders showed a downward trend， and the proportion of recorded medical orders of off-label use had increased from 17.33％ in 2013 to 84.00％ in 2016. CONCLUSIONS： The management system for off-label drug use in medical institutions can effectively improve the clinical understanding of off-label drug use， standardize the behavior of off-label drug use.

Effect of Standardization of Medical Record Management / 现代医院

Objective To identify the problems of medical record management standardization in clinical case management for the study of medical record quality and give some corresponding measures.Methods 3,000 medical records of patients in our hospital from January 2015 to December 2016 were collected and divided into control group (with 1,500 records from January 2015 to December 2015) and observation group (with 1,500 clinical medical records from January 2016 to December 2016).The control group adopted regular data management while the observation group employed standardized lean management.Medical record defects, rectification rate and the average scores of inpatient medical records between the two groups were compared and analyzed.Results The average score of inpatient medical records in observation group was significantly higher than that of the control group (t=13.672, P<0.05), while the defect degree and the modification rate of the medical records were significantly lower than those of the control group (P<0.05).Conclusion Standardized medical record management contributes to the improvement of the quality of medical records.

Individual Monitoring and Occupational Dose Record Management in China: History, Current Status and Perspectives.

This review paper presents an overview of individual monitoring, as well as the national dose register and dose record management of radiation workers in China. Progress has recently been made on the individual monitoring of radiation workers. A critical analysis of current status and problems in individual monitoring is also presented and necessary future research on individual monitoring, such as the monitoring technology in the form of the ring dosimeters and eye lens dosimeters, is suggested.

Gestión documental, de información, del conocimiento e inteligencia organizacional: particularidades y convergencia para la toma de decisiones estratégicas / Record, information and knowledge management and organizational intelligence: distinguishing features and convergence in strategic decision making

El objetivo de este trabajo es identificar los elementos, procesos y sistemas de información relacionados con la gestión documental, la gestión de información, la inteligencia organizacional y la gestión del conocimiento que inciden en la toma de decisiones estratégicas de instituciones de información. Se utilizó el análisis documental para examinar los componentes y características particulares de cada uno de estos procesos gerenciales y el modo en que inciden en los máximos niveles de decisión organizacional de las instituciones de información. Se realizó un análisis descriptivo para esclarecer y precisar los recursos, los procesos y los sistemas informacionales que intervienen en la toma de decisiones estratégicas de bibliotecas, archivos y centros de información de amplio reconocimiento para el sector de las Ciencias de la Información en Cuba. Los documentos archivísticos, la información organizacional interna y externa y el conocimiento constituyen recursos clave para la toma de decisiones estratégicas. Entre los componentes asociados a estos procesos gerenciales se destacan los sistemas de gestión documental y los sistemas de información organizacional. Los procesos informacionales y cognitivos que inciden en la toma de decisiones son la identificación de necesidades de información y los flujos informativos, la búsqueda y selección de información, al análisis, así como la creación y uso de conocimiento organizacional. La toma de decisiones ha adquirido una marcada dependencia hacia los procesos gerenciales relacionados con la información y el conocimiento; de ahí su carácter informacional, por lo que se requiere una adecuada proyección e interrelación de estos para garantizar decisiones efectivas sobre la base de un buen uso de estos recursos estratégicos(AU)

The study is aimed at identifying the information systems, elements and processes related to record, information and knowledge management and organizational intelligence which influence strategic decision making at information institutions. Document analysis was used to examine the particular characteristics and components of each of these management processes, as well as their influence on the top levels of organizational decision making at information institutions. A descriptive analysis was performed to clarify and accurately determine the information systems, resources and processes involved in strategic decision making at libraries, archives and information centers of broad recognition in the sector of information sciences in Cuba. Archival documents, internal and external organizational information, and knowledge are key resources in strategic decision making. Document management and organizational information systems stand out among the components associated to these management processes. The information and cognitive processes influencing decision making are the identification of information needs and information flows, the search for and selection of information, and the creation, analysis and use of organizational knowledge. Decision making has become heavily dependent on management processes related to information and knowledge, hence its informational nature. Therefore, these strategic resources should be appropriately projected and interrelated to ensure the effectiveness of decisions(AU)

Gestión documental, de información, del conocimiento e inteligencia organizacional: particularidades y convergencia para la toma de decisiones estratégicas / Record, information and knowledge management and organizational intelligence: distinguishing features and convergence in strategic decision making

El objetivo de este trabajo es identificar los elementos, procesos y sistemas de información relacionados con la gestión documental, la gestión de información, la inteligencia organizacional y la gestión del conocimiento que inciden en la toma de decisiones estratégicas de instituciones de información. Se utilizó el análisis documental para examinar los componentes y características particulares de cada uno de estos procesos gerenciales y el modo en que inciden en los máximos niveles de decisión organizacional de las instituciones de información. Se realizó un análisis descriptivo para esclarecer y precisar los recursos, los procesos y los sistemas informacionales que intervienen en la toma de decisiones estratégicas de bibliotecas, archivos y centros de información de amplio reconocimiento para el sector de las Ciencias de la Información en Cuba. Los documentos archivísticos, la información organizacional interna y externa y el conocimiento constituyen recursos clave para la toma de decisiones estratégicas. Entre los componentes asociados a estos procesos gerenciales se destacan los sistemas de gestión documental y los sistemas de información organizacional. Los procesos informacionales y cognitivos que inciden en la toma de decisiones son la identificación de necesidades de información y los flujos informativos, la búsqueda y selección de información, al análisis, así como la creación y uso de conocimiento organizacional. La toma de decisiones ha adquirido una marcada dependencia hacia los procesos gerenciales relacionados con la información y el conocimiento; de ahí su carácter informacional, por lo que se requiere una adecuada proyección e interrelación de estos para garantizar decisiones efectivas sobre la base de un buen uso de estos recursos estratégicos.

The study is aimed at identifying the information systems, elements and processes related to record, information and knowledge management and organizational intelligence which influence strategic decision making at information institutions. Document analysis was used to examine the particular characteristics and components of each of these management processes, as well as their influence on the top levels of organizational decision making at information institutions. A descriptive analysis was performed to clarify and accurately determine the information systems, resources and processes involved in strategic decision making at libraries, archives and information centers of broad recognition in the sector of information sciences in Cuba. Archival documents, internal and external organizational information, and knowledge are key resources in strategic decision making. Document management and organizational information systems stand out among the components associated to these management processes. The information and cognitive processes influencing decision making are the identification of information needs and information flows, the search for and selection of information, and the creation, analysis and use of organizational knowledge. Decision making has become heavily dependent on management processes related to information and knowledge, hence its informational nature. Therefore, these strategic resources should be appropriately projected and interrelated to ensure the effectiveness of decisions.

La gestión de documentos de archivo en el actual contexto organizacional y la introducción a la Norma ISO 15489 / The archive documents management in the current organizational context and introduction to ISO 15489 Standard

Se aborda la gestión documental en el contexto organizacional actual. Se examina el concepto de documento de archivo y las complejidades de su manejo en el ambiente digital que afectan su capacidad de constituir evidencia veraz de los procesos de negocios organizacionales. Finalmente se presenta la Norma ISO 15489 Información y documentación Gestión de Documentos como una metodología útil para la adecuada gestión de documentación archivística, independientemente de su soporte, en el contexto organizacional. Se ofrecen consideraciones finales y recomendaciones(AU)

The documentary management in the current organizational context is approached. The concept of archive document and the complexity of its management in the digital environment affecting its ability to create a truthful evidence of processes of organizational business are examined. Finally, the ISO 15489 Standard is presented: Information and documentation document management as a useful methodology for a appropriate management of archives documents, independently of its support in the organizational context. Final considerations and recommendations are offered(AU)

La gestión de documentos de archivo en el actual contexto organizacional y la introducción a la Norma ISO 15489 / The archive documents management in the current organizational context and introduction to ISO 15489 Standard

Se aborda la gestión documental en el contexto organizacional actual. Se examina el concepto de documento de archivo y las complejidades de su manejo en el ambiente digital que afectan su capacidad de constituir evidencia veraz de los procesos de negocios organizacionales. Finalmente se presenta la Norma ISO 15489 Información y documentación Gestión de Documentos como una metodología útil para la adecuada gestión de documentación archivística, independientemente de su soporte, en el contexto organizacional. Se ofrecen consideraciones finales y recomendaciones

The documentary management in the current organizational context is approached. The concept of archive document and the complexity of its management in the digital environment affecting its ability to create a truthful evidence of processes of organizational business are examined. Finally, the ISO 15489 Standard is presented: Information and documentation document management as a useful methodology for a appropriate management of archives documents, independently of its support in the organizational context. Final considerations and recommendations are offered

Development of modern medical record management and required qualities of its managerial personnel / 医学研究生学报

Modern medical record management is becoming more and more integrated with medical information management and computerization.With the changes in the content and mode of medical record management,the modernization of its means and the extension of its services,the managerial personnel must have such qualities as active service idea,multiple knowledge,a high sense of information,strengthened awareness of law,and abilities of communication and coordination,so as to meet the requirement of modern medical record management.

Survey of the condition of medical record management personnel in 98 hospitals of Jiangxi Province / 中华医院管理杂志

Objective To find out about the current situation of the development of medical record management in Jiangxi Province. Methods Questionnaires were distributed to 182 medical record management workers in 98 hospitals of Jiangxi Province. Results Medical record management has witnessed slow development and the management contingent is characterized by low educational level, low professional titles, a rather limited number of years of work experience and numerical dominance of women. Conclusion That leaders in some hospitals fail to pay enough attention to medical record management and medical record management organizations have not been properly set up constitutes the chief cause of the slow development of the medical record management specialty in Jiangxi Province.

The application of multi-media technique in the control system of medico-scientific research records / 中华医院管理杂志

To change the old stereotype of using literal and data information for storage and ex- change in medico—scientific records and provide a new record version rich in word and picture,a gener- al model of multi—media control system of medical records and an information storage pattern have been developed and the feasibility of development methods explored.