Electronic discharge summary driving advice: Current practice and future directions

Electronic Medical Record Documentation of Driving Safety for Veterans with Diagnosed Dementia

OBJECTIVES

Many older adults continue to drive following dementia diagnosis, with medical providers increasingly likely to be involved in addressing such safety concerns. This study examined electronic medical record (EMR) documentation of driving safety for veterans with dementia (N = 118) seen in Veterans Affairs primary care and interdisciplinary geriatrics clinics in one geographic region over a 10-year period.

METHODS

Qualitative directed content analysis of retrospective EMR data.

RESULTS

Assessment of known risk factors or subjective concerns for unsafe driving were documented in fewer than half of observed cases; specific recommendations for driving safety were evident for a minority of patients, with formal driving evaluation the most frequently documented recommendation by providers.

CONCLUSION

Utilizing data from actual clinical encounters provides a unique snapshot of how driving risk and safety concerns are addressed for veterans with dementia. This information provides a meaningful frame of reference for understanding potential strengths and possible gaps in how this important topic area is being addressed in the course of clinical care.

CLINICAL IMPLICATIONS

The EMR is an important forum for interprofessional communication, with documentation of driving risk and safety concerns an essential element for continuity of care and ensuring consistency of information delivered to patients and caregivers.

Semantic-Web Architecture for Electronic Discharge Summary Based on OWL 2.0 Standard

Introduction:

Patients’ electronic medical record contains all information related to treatment processes during hospitalization. One of the most important documents in this record is the record summary. In this document, summary of the whole treatment process is presented which is used for subsequent treatments and other issues pertaining to the treatment. Using suitable architecture for this document, apart from the aforementioned points we can use it in other fields such as data mining or decision making based on the cases.

Material and Methods:

In this study, at first, a model for patient’s medical record summary has been suggested using semantic web-based architecture. Then, based on service-oriented architecture and using Java programming language, a software solution was designed and run in a way to generate medical record summary with this structure and at the end, new uses of this structure was explained.

Results:

in this study a structure for medical record summaries along with corrective points within semantic web has been offered and a software running within Java along with special ontologies are provided.

Discussion and Conclusion:

After discussing the project with the experts of medical/health data management and medical informatics as well as clinical experts, it became clear that suggested design for medical record summary apart from covering many issues currently faced in the medical records has also many advantages including its uses in research projects, decision making based on the cases etc.