Patient Records Management

Patient records management is the systematic creation, organization, storage, retrieval, retention, and protection of information about a person's health and care. It relies on standardized documentation, patient identifiers, electronic health record systems, role-based access controls, and audit trails to keep data accurate, available to authorized users, and traceable over time. In clinical practice, effective patient records management supports continuity of care, communication among healthcare professionals, safer decision-making, regulatory compliance, and secure data sharing; well-maintained records also provide reliable material for quality improvement, outcomes assessment, and clinical research.

Patient Records Management - Related Videos

Research

JoVE Journal - Medicine
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Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

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Cited by 5 •

2016

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Education

JoVE Core - Nursing

Data Reporting and Recording

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2023

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

Research

JoVE Journal - Medicine
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Breathing-controlled Electrical Stimulation (BreEStim) for Management of Neuropathic Pain and Spasticity

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Cited by 9 •

2013

The purpose is to present a new method, breathing-control electrical stimulation (BreEStim) for management of neuropathic pain and spasticity.

Research

JoVE Journal - Medicine
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Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management

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Cited by 6 •

2017

This study presents a novel method to provide efficient patient temperature control for cooling or warming patients. A single use, triple lumen device is placed into the esophagus, analogous to a standard orogastric tube, and connects to existing heat exchange units to perform automatic patient temperature management.

Early Intervention and Pain Management

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2026

All animal procedures described here must be conducted in accordance with institutional animal ethics guidelines and approved by IACUC. All procedures must follow the principles of the 3Rs—Replacement, Reduction, and Refinement—and must be performed by trained personnel. Monitoring Animals for Signs of Pain and Distress Recognizing early signs of pain is essential for ethical animal research. Animals are routinely monitored using behavioral, physical, and physiological parameters that reflect...

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