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Medical records: one variation of physicians' language1 MARGARET M. VAN NAERSSEN Introduction This is the 1 st RH admission for this 40 y o w male who presents with lethargy X 3 days . .. Diagnosis 1) Internal Carotid aneurysm, Cerebral Herniation . . . Patient pronounced dead on 1/20/77 .. . Kidneys donated in OR . . . This discussion of medical records as one variation of physicians' language falls into four parts. First, medical records are characterized as one instance of physicians' communication, and the process by which medical records are created is

41 2 Anticontagionism and History’s Medical Record t h i s ess ay wa s w r i t t en in the late 1970s for a volume setting out what was then the new social constructivist approach to medical knowledge.i Drawing on Frankfurt School critical theory, the rediscovery of the early Marx, and the ideas of Antonio Gramsci, it was an attempt to illustrate how knowledge production (held as class production) and power relations were mutually constitutive or interpenetrated. Whereas so- called vulgar Marxism had interpreted knowledge production in terms of an


A semantic-based search engine for clinical data would be a substantial aid for hospitals to provide support for clinical practitioners. Since electronic medical records of patients contain a variety of information, there is a need to extract meaningful patterns from the Patient Medical Records (PMR). The proposed work matches patients to relevant clinical practice guidelines (CPGs) by matching their medical records with the CPGs. However in both PMR and CPG, the information pertaining to symptoms, diseases, diagnosis procedures and medicines is not structured and there is a need to pre-process and index the information in a meaningful way. In order to reduce manual effort to match to the clinical guidelines, this work automatically extracts the clinical guidelines from the PDF documents using a set of regular expression rules and indexes them with a multi-field index using Lucene. We have attempted a multi-field Lucene search and ontology-based advanced search, where the PMR is mapped to SNOMED core subset to find the important concepts. We found that the ontology-based search engine gave more meaningful results for specific queries when compared to term based search.

Int J Adolesc Med Health 2003; 15(2): 153-160. ©Freund Publishing House Ltd. Introduction of computerized medical records. A survey of primary physicians J a c o b U r k i n , M D , D a n G o l d f a r b , M D and D e n i s W e i n t r a u b , A M , M A Clalit Health Services, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel Abstract: The purpose of the study was to survey primary physicians about the possible impact of computerized medical records on clinical practice. Methods and design: 236 primary care physicians from

, usually termed health-associated or population-based [5, 6], derived from a sample of individuals who are in “good health”. The other type is a DL, based on specific limits that national and international expert clinicians decide are helpful to diagnose and/or manage patients [7]. Usually a DL is the result of extensive medical research. Here, we describe a simple method for deriving risk-based DLs from data available in the Electronic Medical Record (EMR). The underlying assumption in RIs is that the population mean represents optimal health, i.e., good functionality


This review attempts to address the question: is the Electronic Medical Record (EMR) our best friend or sworn enemy in the context of Clinical Governance and Laboratory Medicine? It provides a brief overview of the history and development of Clinical Governance before going on to define an EMR. It considers how EMRs could assist in delivering quality care in laboratory medicine. A number of outstanding issues regarding EMRs and electronic health records (EHRs) are identified and discussed briefly before the author provides a brief outlook on the future of clinical governance and EMRs in laboratory medicine.

Opinion no 104: The “Personal Medical Record” and Computerisation of Health-Related Data∗ Comité Consultatif National d’Éthique pour les Sciences de la Vie et de la Santé (CCNE), France (May 2008) Introduction On March 19, 2008, the French Minister for Health, Madame Roselyne Bachelot, referred to the National Consultative Ethics Committee (CCNE) for an opinion on the development of informa- tion technology in a medical context. The referral bore on the risk of loss of confidentiality of medical data in patient records due to electronic

is a physician and researcher). The OpenNotes system allows patients to read their full medical records, including the doctors’ clinic notes, via secure patient portals using the Internet ( ). I actually tried to sign up to read my medical record this month and was not allowed. While the OpenNotes system has exploded in popularity and is rapidly spreading across the country, only adult patients are allowed to see their electronic records in most health care systems, restricting teens like me from the potential benefit of this online information

interpretative caution in order to understand the patient’s inner perspective ( Dalferth 2016). In other words, a preconceived opinion on hope prevents from grasping what patients and family actually mean when they speak about hope ( Bühler & Peng-Keller 2014). This stumbling block drew our attention while reading and analysing 300 palliative patients’ medical records collected at three Swiss university hospitals between April and September 2016. Since qualitative research design helps to investigate medical staff’s written statements about patients in more depth than