Class Acvity HIS 340: EHR - Week 3 (September 6 2023) by Nasriah Zakaria

Class Acvity HIS 340: EHR - Week 3 (September 6 2023) by Nasriah Zakaria https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2 en-us 2023-09-06 15:10:45 UTC 2024-10-06 10:34:05 UTC hello@padlet.com Task 1: Paper Medical Record : Share One image of a medical record here (see Example below) nasriah_zakaria https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2686930907 Link: https://www.researchgate.net/publication/220879543_Mobility_in_Collaboration/figures?lo=1https://www.researchgate.net/publication/220879543_Mobility_in_Collaboration/figures?lo=1]]> 2023-09-06 15:11:17 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2686930907 Task 2: Discussion Points nasriah_zakaria https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2686936435 Point 1: Comment on the legibility of handwriting on the paper medical record
Point 2: List five numerical data available on a medical record
Point 3: List three free text data available on a medical record
Point 4: Discuss how paper medical records are stored in hospitals
Point 5: Choose one of your friend's posts and comment on his/her assignment (Task 1 & Task2) ]]> 2023-09-06 15:14:09 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2686936435 Welcome to our Class Activity using Padlet nasriah_zakaria https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2686961220 Kindly post your work (Task 1 + Task 2) by clicking "+" on bottom right page of Padlet

You can add images and text to your board ]]> 2023-09-06 15:25:23 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2686961220 Task 1 - Nour Asfari https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687080874 2023-09-06 16:29:30 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687080874 Task 2 - Nour Asfari https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687096618 1) The hand writing is not clear, it is hard to recognize it and it takes time to understand it. Plus not everyone have the ability or skill to recognize hard handwritings.

2) BP , HR , RR , T , O2 sat

3)
- HPI (history of present illness)
- PMH (past medical history)
- Allergies

4) They are stored in physical filing cabinets, fireproof safes and lockboxes, off-site storage facilities, or safety deposit boxes. With different filing and tracking systems to organize, store and retrieve the records.

5) My comment on Yara's post:
Yes I do really agree that the pic she posted has an unreadable and unclear handwriting which can lead to medical errors.

And about the 4th answer, very great detailed answer about filing systems and storing types of paper medical records.

]]> 2023-09-06 16:39:13 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687096618 Task 1 - yara asiri https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687099078 2023-09-06 16:40:42 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687099078 Task 2 - yara asiri https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687136692

Point 1-
I think it’s one of the biggest problems in paper medical records that there’s people with very bad hand writing as you see in the image that can cause serious problems and miss understanding

Point 2-

Height

Weight

Age

Date

BMI

Point 3-

clinical notes

Assessment and plan

Allergies

Point 4-

Paper medical records need to be stored in safe, reliable and secure facilities. At the same time, they need to be organised and easy to access at all times. Using filing cabinets for medical records is advisable. In other words, you want to organise them systematically. Keeping your paper medical records in an off-site storage facility will protect them from damage, fire or flooding. Create physical safeguards. These safeguards can include measures such as maintaining a double lock rule. The double lock rule dictates that if you are storing medical records in a locked cabinet, that cabinet should also be kept within a locked room.

Point 5 - (fatima)
The image she put has the same problem with mine a bad handwriting and we agree on that ,And I also agree with her on point 4 .
Great discussion overall.

]]> 2023-09-06 16:47:33 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687136692 Fatima Basudan task1&task2 https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687143596 1:Many details in this medical record are inaccessible to auditors, researchers, and other professionals involved in the patient's treatment due to bad handwriting.

2: DATE/WT/TEMP/HT/PULSE

3:Physical Exam/Impression/Treatment

4:It is stored as folders with alphabetic or numeric labeling, as well as optional chart dividers, are used to organize paper medical information. They are kept on shelving units, in vertical or lateral file cabinets, or both.

5: I would like to comment on Nour’s answers,
She almost covered all the points well! And her report was more detailed and it has too many information so,that’s why I agree with Nour that the report was vary difficult to understand. ]]> 2023-09-06 16:51:39 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687143596 Task 1 - Abdulelah Alanazi https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687191082 2023-09-06 17:14:30 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687191082 Task 2 - Abdulelah Alanazi https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687200603 Point 1: Handwriting legibility on paper medical records can vary significantly. Some healthcare providers may have clear and easily readable handwriting, while others may have more challenging handwriting, leading to potential issues with interpretation and understanding of the information documented.

Point 2: Five numerical data commonly found on a medical record include:
1. Patient's age
2. Height and weight
3. Blood pressure readings
4. Lab test results (e.g., glucose level, cholesterol level)
5. Medication dosage and frequency

Point 3: Three examples of free text data often included in medical records are:
1. Chief complaint or reason for the patient's visit
2. Physician's notes and observations during the examination
3. Patient's medical history, including past illnesses, surgeries, and allergies

Point 4: Paper medical records are typically stored in hospitals using various methods, depending on the facility's resources and practices. Some common storage methods include:
1. Filing cabinets: Paper records are organized alphabetically or by medical record number and stored in locked filing cabinets.
2. Medical record rooms: Dedicated rooms or areas where paper records are stored securely, often with controlled access and environmental controls to preserve the integrity of the documents.
3. Off-site storage: In some cases, hospitals may choose to store older or less frequently accessed paper records in secure off-site storage facilities to free up space and ensure their long-term preservation.

5.(Jalal) The medical file is very clear and all patient examinations are included in the report, and the handwriting is almost acceptable]]> 2023-09-06 17:19:20 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687200603 Task 1 - Jalal https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687229642 2023-09-06 17:34:52 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687229642 Task 2 - Jalal https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687283901 1. not very clear, spelling errors
2. weight , temperature , pulse
height (missing) , blood pressure (missing)
3. complaint , medical history , physical exam , treatment plan
4. Paper medical records are stored in a variety of ways, depending on the hospital. however they must be stored in a safe and secure location, so only authorized personnel have access to them. There must be a logging system so administration can keep track of the records.

5. (Abdulelah)
handwriting is more legible than the average Iv'e seen in my search.
I liked the elaborative explanation of how paper records are stored. ]]> 2023-09-06 18:09:18 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687283901 Task 1 - Sarah Moctar https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687358136 2023-09-06 19:01:59 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687358136 Task 2 - Sarah Moctar https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687362991

1: The legibility of handwriting on paper medical records can be a serious issue, resulting in information misunderstanding and errors in patient treatment.

2: Personal data, progress notes, health issues, prescriptions, vital signs, past medical history, vaccines, test findings, and radiology reports are all examples of numerical data included in a medical record.

3: Symptoms, progress notes, diagnoses.

4: To organize, store, and retrieve data, a variety of file and tracking solutions are employed, including physical cabinets, fireproof safes, off-site facilities, and safety deposit boxes.

5: My comment on ( Abdulelah) The handwriting in the photo is difficult to read and illegible, potentially causing medical errors. The fourth response provides a comprehensive explanation of file systems and paper medical document storage.

]]> 2023-09-06 19:05:59 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687362991 Task1 - Ahmad AlYahya https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687371340 2023-09-06 19:13:23 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687371340 Task2 - Ahmad AlYahya https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687419266 Point 1: In the image I posted in task 1, I think that the handwriting is not that bad. But still not everyone can write neatly, therefore hand written medical records could lead to poor information accuracy & quality that leads to medical errors..

Point 2: hight , weight, age, head circumf, date

Point 3: assessment , plan, physical exam findings

Point 4: Paper medical records are stored in hospitals in various ways, including metal filing cabinets, fireproof safes, off-site storage facilities, or secure deposit boxes. A logging system is necessary to track these records and ensure that only authorized personnel have access.

Point 5: Regrading Nour’s post i find that the handwriting in the paper she posted as she said “it is not that clear” , I agree with her thought about the error that may occur due to this. Her answers are well detailed.]]> 2023-09-06 19:50:04 UTC https://padlet.com/nasriah_zakaria/39oihpnol5o63ql2/wish/2687419266