The Medical Record as Evidence

The Medical Record as Evidence PDF

Author: Elliott Oppenheim

Publisher: ATOM Press

Published: 2012-08

Total Pages: 1001

ISBN-13: 0984240578

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Elliott B. Oppenheim practiced family medicine and emergency medicine for nearly eighteen years before attending law school and obtaining a master's degree in health law. He attended Occidental College (BA 1969), The University of California at Irvine (MD 1973), Detroit College of Law at Michigan State University (JD 1995), and Loyola University School of Law, Chicago (LL.M. Health Law 1996). He has written extensively about medical malpractice litigation, the Emergency Medical Treatment and Active Labor Act, and spoliation of evidence in medical negligence litigation and continues to write on medical-legal subjects. Dr. Oppenheim has been active in the field of medical negligence litigation for almost twenty-five years. He heads coMEDco, Inc., a national medical-legal consulting firm as President and CEO. Dr. Oppenheim also teaches health law. SUMMARY TABLE OF CONTENTS Chapter 1. Admissibility of Medical Records Chapter 2. The Recording Sequence Chapter 3. Why There Must Be a Record Chapter 4. Spoliation Chapter 5. Confidentiality and Privilege Chapter 6. Discovery and Trial Techniques This book is a pdf made from a high quality scan of the original.

Registries for Evaluating Patient Outcomes

Registries for Evaluating Patient Outcomes PDF

Author: Agency for Healthcare Research and Quality/AHRQ

Publisher: Government Printing Office

Published: 2014-04-01

Total Pages: 396

ISBN-13: 1587634333

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This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

The Computer-Based Patient Record

The Computer-Based Patient Record PDF

Author: Committee on Improving the Patient Record

Publisher: National Academies Press

Published: 1997-10-28

Total Pages: 257

ISBN-13: 030957885X

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Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Key Capabilities of an Electronic Health Record System

Key Capabilities of an Electronic Health Record System PDF

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2003-07-31

Total Pages: 36

ISBN-13: 0309185432

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Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.

The Medical Record as a Forensic Resource

The Medical Record as a Forensic Resource PDF

Author: Campion Quinn

Publisher: Jones & Bartlett Publishers

Published: 2005

Total Pages: 300

ISBN-13:

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This books seeks to bridge the gap of understanding between the legal world and the world of medicine, providing insight into the creation of the medical chart for non-medical professionals, such as lawyers. Examples, explanations and checklists are provided to aid the reviewer.

Evidence-Based Medicine and the Changing Nature of Health Care

Evidence-Based Medicine and the Changing Nature of Health Care PDF

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2008-09-06

Total Pages: 202

ISBN-13: 0309113695

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Drawing on the work of the Roundtable on Evidence-Based Medicine, the 2007 IOM Annual Meeting assessed some of the rapidly occurring changes in health care related to new diagnostic and treatment tools, emerging genetic insights, the developments in information technology, and healthcare costs, and discussed the need for a stronger focus on evidence to ensure that the promise of scientific discovery and technological innovation is efficiently captured to provide the right care for the right patient at the right time. As new discoveries continue to expand the universe of medical interventions, treatments, and methods of care, the need for a more systematic approach to evidence development and application becomes increasingly critical. Without better information about the effectiveness of different treatment options, the resulting uncertainty can lead to the delivery of services that may be unnecessary, unproven, or even harmful. Improving the evidence-base for medicine holds great potential to increase the quality and efficiency of medical care. The Annual Meeting, held on October 8, 2007, brought together many of the nation's leading authorities on various aspects of the issues - both challenges and opportunities - to present their perspectives and engage in discussion with the IOM membership.

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