====== Medical record ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1zixKHrauafWxGpcSL9xokqiy6gTop5AZsqAvML6rn3BLlmQab/?limit=15&utm_campaign=pubmed-2&fc=20240202112424}}
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A medical [[record]] is simply a record of a patient's health and [[medical history]]. Depending on the level or need of care a patient has, records may vary, but all medical records will contain some common information.
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The practice of medicine is advanced by self-reflection and a desire to improve the care of patients through the refinement of procedures and medical regimens. The first systematic record-keeping tool used for improving care was utilized in the late 1800s according to archived records of Cushing and Codman
((Sundararaman LV, Desai SP. The Anesthesia Records of Harvey Cushing and Ernest Codman. Anesth Analg. 2018 Jan;126(1):322-329. doi: 10.1213/ANE.0000000000002576. PMID: 29099433.))
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Between 2013 and 2020, there were 68 wrong-site closed [[claim]]s cases. The mean [[age]] of the [[patient]]s was 55.7 (standard deviation 16.21) years, and 51.5% were female. The services most frequently responsible for these were Orthopedic (35.3%), Neurosurgery (22.1%), and Urology (8.8%). The most common types of [[procedure]]s were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%), and surgery on muscles/tendons (11.8%). The severity of [[claim]]s was higher in the [[inpatient]] setting compared to the [[ambulatory]] setting. The most common alleged injuries included the need for additional surgery (45.6%), [[pain]] (33.8%), mobility dysfunction (10.3%), worsened injury (8.8%), [[death]] (7.4%), and total loss (7.4%). The top contributing factors to wrong-site surgery were failure to follow [[policy]]/[[protocol]] (83.8%) and failure to [[review]] the [[medical record]]s (41.2%). The mean closed claim value was $136,452.84, and 60.3% of cases were settled.

The risk of wrong-site surgeries is increased with spine surgeries, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events
((Tan J, Ross JM, Wright D, Pimentel MPT, Urman RD. A Contemporary Analysis of Closed Claims Related to Wrong-Site Surgery. Jt Comm J Qual Patient Saf. 2023 Feb 11:S1553-7250(23)00053-3. doi: 10.1016/j.jcjq.2023.02.002. Epub ahead of print. PMID: 36925434.))
===== Electronic health record =====

see [[Electronic health record]].