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the differences among source oriented records, problem oriented records, and integrated records.
Problem-oriented electronic medical records may have significant advantages over source-oriented organization of patient data. However, reorganizing data in this fashion may have unexpected consequences for the clinical decision-making process. [ To determine what these consequences might be, we conducted a pilot study using verbal protocols and video screen capture to characterize physician
subjects’ use of a traditional laboratory data display while reviewing unfamiliar inpatient cases. We found that subjects navigated to the laboratory display primarily to seek evidence confirming a result or problem identified elsewhere in the case. Additionally, 22% of the time subjects spontaneously reviewed anomalous findings and results related to other known problems. These results suggest that physicians have learned complex data acquisition behaviors for efficient interaction with source-oriented displays, and further study is needed to ensure that problem-oriented medical records do not lose the benefits of these behaviors. ]
Expert answered|AwesomeGuy200|Points 1123|
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Asked 6/29/2012 8:42:38 PM
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What do you think is the reasoning for not filing incident reports in medical records? Provide examples of three incidents and explain why they could be problematic in patients’ files.
Weegy: Some of the reasons that incident reports are not filed when they should be are somebody deliberately does not want the incident to be reported, somebody didn't think the incident was of credible importance to be reported, [ or filing an incident report was simply forgotten about. Why this is a serious issue The first example of why not filing an incident report could be problematic is in when a patient has been given their latest round of medication. If the dosage has been given to the patient but this dosage has not been noted in the incident reports, this could lead to the dosage being issued again. This would be very dangerous and potentially lethal for that patient. Incorrect medication can be given, endangering lives Another example would be if it has been discovered that the patient has an allergic reaction to a particular medicine or food which is then given to them unknowingly. Of course, medical records will often highlight this information, but if it is something that is only discovered later on, it is important that all of the staff caring for that patient are well aware. The final example could be in the event of any new conditions or symptoms developing for a patient. If the condition of the patient changes, it is important that all medical professionals involved with this patient are fully aware. This is so that the correct action can be taken in the event of something happening. ] (More)
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Asked 6/28/2012 10:43:17 PM
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where would you place the advanced directives in the paper chart if you were working in a medical records department at the primary care clinic
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Asked 6/28/2012 11:43:18 PM
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the differences among source oriented records, problem oriented records, and integrated records.
Weegy: In a POMR or problem oriented medical record, the record is kept together by problem number (a number is assigned to each problem. Progress notes in these records are kept in SOAP format. [ S=subjective (chief complaint, present illness), O=objective (physical exam, labs), A=assessment (diagnosis, prognosis), P=plan (treatment). Read more: ] (More)
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Asked 6/29/2012 9:06:49 PM
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