Medical and Nursing Documentation

Garant předmětu:

Lecturer:

Tutor:

Supervisor:

Department of Biomedical Informatics

Synopsis:

The course are focused on basic principles and concepts of medical and nursing documentation. The topic for this course is the main structure of the ambulatory check-ups, the structure of the records of patient hospitalization, the emphasis will be given to the specific clinical departements, such as oncology, internal medicine, traumatology, surgery etc. The seminar also provides an introduction to main code classification systems (scores) specific to individual disciplines - TNM, FIGO, Child - Pugh, Karnofsky, Ishak, etc. In the last lessons the students learn the fundamentals of nursing documentation and the basic standards of nursing care.

Requirements:

80% attendance at lectures. Preparation of a proposal of a simple medical database application. Prezentation of this application.

Syllabus of lectures:

1. Design of the basic databases for medical documentation

2. Personal and family anamnesis (free text versus coded data)

3. Ambulatory ceck-ups (free text versus coded data)

4. Hospitalization of patient (free text versus coded data)

5. Reports

6. Forms and Recipes

7. Oncology - Diagnosis, Follow Up (free text versus coded data)

8. Oncology - different types of therapies and the method of assessing the success of the therapy (free text versus coded data)

9. Internal branches

10. Surgery branches

11. Laboratory examinations - Biochemistry, Hematology, Alergology, Microbiology (free text versus coded data)

12. Diagnostic imaging methods

13. Nursing documentation, standards of nursing care

Syllabus of tutorials:

no excercises

Study Objective:

To introduce students with basic terminology of medical and nursing documentation

To introduce students to the basic structure of the medical record - in both paper and electronic form

Highlighted the differences between free text and coded data

To show to students that medical record has today a comprehensive purpose: „to recall observation, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify intervention.“

Prepare students for their own creation of medical documantation and assessment of various medical information systems

Study materials:

[1] J. H. Van Bemmel, M. A. Musen: Handbook of medical informatics, IOS Press. 1998

[2] Omar Al-Ghamdi: A Clinical Aspect of the Computer-Based Patient Record: Free Text versus Coded Data (http://www.informatics-review.com/thoughts/freetext.pdf)

[3] Stephen H. Walsh: The Clinician's Perspective on Electronic Health Records and How They Can Affect Patient Care, BMJ 2004, 328; 1184 - 1187

[4] Athine A. Lazakidou: Handbook of research on Biocomputation and Biomedical Informatics: Case Studies & Applications, University of Piraeus, Greece, 2008

Note:

Further information:

No time-table has been prepared for this course

The course is a part of the following study plans:

• Biomedical Informatics - combined study (compulsory elective course)