This register contains information regarding all healthcare contacts with care providers organized by the Stockholm County Council that have rendered notes (documentation of care) in the medical records.
IMSS' EHR consists of several linked databases which include information on appointments; medical history; physical examination; clinical encounter notes; aspects of care and progress for patients with specific conditions (diabetes, antenatal care, hypertension); social work, occupational health, dietary, and preventive care services.
Note that point-of-care laboratory testing is not only logistically simpler and economically more pragmatic, but seems to lead to the same or even better therapeutic control compared to usual laboratory testing [ 29, 30].
The neonatal chart notes, or records of care, were found in disparate locations in the different facilities: in 3 facilities neonatal case notes were found in local school exercise books "daftari" as shown in Figure 2, 8 hospitals detailed neonatal care in the mothers' case notes, and 2 hospitals used standard medical files specific to the neonate.
[ 13- 15] Dixon's research group noted diminished quality of care for patients with both serious mental illness (schizophrenia or major mood disorder) and diabetes, relative to patients with diabetes alone, in their study of quality indicators.
The duplicative processes involved in maintaining the electronic record as well as clinical notes and cycles of care information meant that without payment for the extra time spent, fewer clinicians were interested in using the record.
The pre-invention IDR note completion rate, as measured by number of patients with a note per ward days of care, was 27%% over an 85-day observation period; post-intervention completion rate was 69%% over 119 days, with the post-intervention center line exceeding the pre-intervention upper confidence limit.
Nurses stressed that a quality note should include documentation of care and education delivered to the patient, information that patients add to their own notes, interdisciplinary information from the various health care providers involved in the patient's care, and infection alerts when a patient's care required attention to infection control.
Of the 700 randomly selected records that met these criteria, 601 (85.9%) had a progress note on the day of care, and 553 (92%) of these were found by chart review to have evidence of SUD treatment.
Of note, health care providers were found to be poor predictors of patient medication adherence, misjudging adherence in 30% to 41% patients in one study (Paterson et al 2000).
