MyMedR

Fulltext An audit of inpatient case records and suggestions for improvements

Arshad AR, Ganesananthan S, Ajik S

Med J Malaysia, 2000 Sep;55(3):331-40.

PMID: 11200713

A study was carried out in Kuala Lumpur Hospital to review the adequacy of documentation of bio-data and clinical data including clinical examination, progress review, discharge process and doctor's identification in ten of our clinical departments. Twenty criteria were assessed in a retrospective manner to scrutinize the contents of medical notes and subsequently two prospective evaluations were conducted to see improvement in case notes documentation. Deficiencies were revealed in all the criteria selected. However there was a statistically significant improvement in the eleven clinical data criteria in the subsequent two evaluations. Illegibility of case note entries and an excessive usage of abbreviations were noted during this audit. All clinical departments and hospitals should carry out detailed studies into the contents of their medical notes.

Matched MeSH terms: Medical Records/standards*

Guidelines on retention of pathology records and materials, Part I (version 1/2005)

College of Pathologists, Academy of Medicine of Malaysia, Ministry of Health Malaysia

Malays J Pathol, 2005 Jun;27(1):51-6.

PMID: 16676694

Matched MeSH terms: Medical Records/standards*

Effectiveness of drug allergy card to prevent repeated prescribing of allergenic medications in a Malaysian public hospital

Lee FY, Chan HK, Wong HS

Pharmacoepidemiol Drug Saf, 2019 05;28(5):760-761.

PMID: 30919516 DOI: 10.1002/pds.4780

Matched MeSH terms: Medical Records/standards*

Fulltext A computer program for oesophago-gastro-duodenoscopy records

Paramarajah S

Singapore Med J, 1986 Apr;27(2):114-9.

PMID: 3489292

The feasibility of using a computer database management system based on an 8·bit microcomputer for storing, retrieving and analysing patient data in a limited setting (oesophago·gastro-duodenoscopy records from a peripheral general surgical department over a 1 year period) is presented. A program developed by the author was used to enter the relevant records of 208 patients undergoing the above examination, and to retrieve and analyse any desired data. Compatible statistical and graphics software packages can be used to access and analyse the data and display or print out the results. The limitations and scope for further expansion of the system are discussed.

Matched MeSH terms: Medical Records/standards*

Fulltext Overcoming the barriers to diagnosis of Morquio A syndrome

Bhattacharya K, Balasubramaniam S, Choy YS, Fietz M, Fu A, Jin DK, et al.

Orphanet J Rare Dis, 2014;9:192.

PMID: 25433535 DOI: 10.1186/s13023-014-0192-7

Morquio A syndrome is an autosomal recessive lysosomal storage disease often resulting in life-threatening complications. Early recognition and proficient diagnosis is imperative to facilitate prompt treatment and prevention of clinical complications.

Matched MeSH terms: Medical Records/standards

Fulltext Validation of verbal autopsy: determination of cause of deaths in Malaysia 2013

Ganapathy SS, Yi Yi K, Omar MA, Anuar MFM, Jeevananthan C, Rao C

BMC Public Health, 2017 08 11;17(1):653.

PMID: 28800758 DOI: 10.1186/s12889-017-4668-y

BACKGROUND: Mortality statistics by age, sex and cause are the foundation of basic health data required for health status assessment, epidemiological research and formation of health policy. Close to half the deaths in Malaysia occur outside a health facility, are not attended by medical personnel, and are given a lay opinion as to the cause of death, leading to poor quality of data from vital registration. Verbal autopsy (VA) is a very useful tool in diagnosing broad causes of deaths for events that occur outside health facilities. This article reports the development of the VA methods and our principal finding from a validation study.

METHODS: A cross sectional study on nationally representative sample deaths that occurred in Malaysia during 2013 was used. A VA questionnaire suitable for local use was developed. Trained field interviewers visited the family members of the deceased at their homes and conducted face to face interviews with the next of kin. Completed questionnaires were reviewed by trained physicians who assigned multiple and underlying causes. Reference diagnoses for validation were obtained from review of medical records (MR) available for a sample of the overall study deaths.

RESULTS: Corresponding MR diagnosis with matched sample of the VA diagnosis were available in 2172 cases for the validation study. Sensitivity scores were good (>75%) for transport accidents and certain cancers. Moderate sensitivity (50% - 75%) was obtained for ischaemic heart disease (64%) and cerebrovascular disease (72%). The validation sample for deaths due to major causes such as ischaemic heart disease, pneumonia, breast cancer and transport accidents show low cause-specific mortality fraction (CSMF) changes. The scores obtained for the top 10 leading site-specific cancers ranged from average to good.

CONCLUSION: We can conclude that VA is suitable for implementation for deaths outside the health facilities in Malaysia. This would reduce ill-defined mortality causes in vital registration data, and yield more accurate national mortality statistics.

Matched MeSH terms: Medical Records/standards*

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