By Deb Thompson, Kim Wright
ISBN-10: 1417575425
ISBN-13: 9781417575428
ISBN-10: 1857759397
ISBN-13: 9781857759396
Supplying functional examples for the layout and implementation of a multidisciplinary sufferer checklist, this can be a complete advisor to constructing a unified sufferer list. It demonstrates tips to swap the best way that execs and employees inside hospitals acquire, checklist, shop and use medical information regarding sufferers. It additionally illustrates how medical governance and evidence-based perform could be simply addressed via modernizing medical details perform.
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Extra resources for Developing a Unified Patient Record: A Practical Guide
Example text
5 In an acute environment, continuity of care can be compromised by the number of different healthcare professionals involved in management of the wound. Therefore, the information recorded should provide each healthcare professional with a mental picture of the wound. By recording the information in a standardised way each time the wound is assessed, progress can be easily monitored by looking at the trends the record provides. This allows staff to evaluate the effectiveness of the care the patient is receiving.
3 The use of evidence-based practice within a unified patient record This chapter will describe the origins and importance of evidence-based medicine (EBM), its relationship to evidence-based practice (EBP) and its relevance in the development of what are known as care guides, an integral part of the UPR. 1 Cochrane's first publication was in 1972 and entitled Effectiveness and Efficiency: random reflections on the health service. The Cochrane centre was founded in 1992 as part of the NHS Research and Development programme; this led to the development of the Cochrane Collaboration.
According to van Bemmel and Musen5 'if data are not structured, the EPR is decreased to, at best, an intelligent word processor'. Information for Health1 recommends the introduction of a common coding language to provide the structure needed. As previously explained, existing coding structures are not flexible enough to fulfil the need. Read Codes, a recent and more flexible system used in primary care, is better suited to the task, as it contains clinical terms as well as codes. However, in order to ensure that the system maintains its flexibility, the national strategy names the system of the future as SNOMED CT.
Developing a Unified Patient Record: A Practical Guide by Deb Thompson, Kim Wright
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