Terdapat banyak kekeliruan dalam penyediaan dokumen kerana kurang pemahaman mengenai jenis, tujuan, kandungan dan bentuk. Terdapat pula pelbagai panduan dari pelbagai sumber, kadangkala dari mereka yang dianggap pakar tetapi sebenarnya kurang arif.
Prinsip pertama ialah perbezaan diantara dokumen dengan rekod.
Saya ada menulis penerangan mengenai penyedian dokumen dalam rencana “Tadbir Urus” dan “Pengurusan Kualiti”.
The subject of clinical work process and total patient care is not covered well in most textbooks dealing with clinical methods or medicine in general. Medical students somehow acquire an understanding of the approach to patient care despite (in my opinion) an incoherent exposition to the subject.
A search via the internet result in a fairly long list of articles and posts but few if any describe exactly the processes of patient care. It would appear that understanding of it is assumed. The term process as applied in other industrial endeavors is seldom used in medical circles except when discussing quality management and clinical information systems.
Actually, clinical work processes in the guise of Nursing Process is very familiar to nurses. Unfortunately, it is considered as a special technique rather than something more fundamental. The current feeling is that “Nursing Process” has been superceded by “Nursing Care Plan”.
In practice, the method of caring for patients and their disease guided by a standard sequence of clinical processes is used by all direct care providers (clinicians) be they doctors, nurses, physiotherapists, occupational therapists, speech therapists, nutritionists, counselors, and clinical psychologists. Currently in some instances, optometrists and audiometrists are also care practitioners (manage some patients on their own) and would therefore be guided by the same processes.
You can read my article about this subject entitled “Overview of Clinical Care“.
There is a lot of confusion in concepts and terminology regarding HIS. In 1999-2000 when I was first introduced to the subject of Total Hospital Information System, my own exposure to it was minimal and I wrote (and rewrite) various articles to clarify in my own mind what a hospital information system is meant to be.
I have been a user of HIS for more than twelve years because the hospital that I worked in as a clinician is computerized from the start. At the same time, I have worked with IT and Medical records personnel in various capacities including applications analyst, the Clinical-IT Coordinator and chairman of the hospital’s Medical Records Executive Committee. Also, I volunteered to provide help to other hospitals and their vendors in developing and implementing their HIS. I have also been invited to evaluate systems being proposed and also those already implemented.
The ideas and content of the current article has been used by some people as the basis for preparing the request for proposal (RFP) document for HIS as well as Operations and Maintenance contracts. From time to time I revised my ideas and only now I consider them worth sharing with others through a website.
These set of articles is an exposition of HIS as it is known to-day together with some of my own ideas which may be considered as radical by some. Foremost, is the proposal for differentiating Patient Information Database from the Electronic Medical Record (EMR). The concept proposed, requires differentiation of the two not only in data content and structure but also in the system architecture and system administration. However, I belief that this approach will provide answers as to what the EMR should contain and how it is going to be made available without the necessity of accessing it through a Clinical Information System (CIS). It can be saved and read as a document or image (e.g. PDF).
This approach calls for defining the pertinent data, from the myriad of data that is collected in CIS that is required to be retained or migrated to a new system. I am putting forward suggestions for re-examining our policies and procedures concerning data migration. Personally I belief, from a medico-legal perspective and for continuity of care, it is mandatory only to retain the EMR. The retention of other data is guided by epidemiological, research and business considerations.
I am sharing these articles with you in the hope of a better understanding, on my part, of the subject. If it helps you in any way I would be much elated.