The Download List

The Download List is a pick of my selected references and resource documents from my collection of references and resource documents related to healthcare in general and to health information management/medical records management specifically, to share with you and which might be of interest to you.

Each link below will open in a new tab of your current window. You can then choose to read online, print, or download for free the reference or resource document and save it to your computer.

ACCREDITATION STANDARDS FOR HOSPITALS
Joint Commission International (JCI)
1 Medical Records Review Form flipbook, JCI Hospital Survey Process Guide, 5th Edition, Effective 1 April 2014
The Malaysian Society for Quality in Health (MSQH)
1 SERVICE STANDARD 7 Health Information Management System, Malaysian Hospital Accreditation Standards, 4th Edition, Effective January 2013
 
SOME SELECTED MALAYSIAN LAWS RELATED TO HEALTH INFORMATION MANAGEMENT / MEDICAL RECORDS MANAGEMENT
1 Act 56 Evidence Act 1950
“An Act to define the law of evidence.”
2 Act 254 Limitation Act 1953
“An Act to provide for the limitation of actions and arbitrations.”
3 Act 586 Private Healthcare Facilities And Services Act 1998
“An Act to provide for the regulation and control of private healthcare facilities and services and other health-related facilities and services and for matters related hereto.”
4 Act 629 National Archives Act 2003
“An Act to provide for the creation, acquisition, custody, preservation,use and management of public archives and public records; and for other matters connected therewith.”
5 Act 709 Personal Data Protection Act 2010
“An Act to regulate the processing of personal data in commercial transactions and to provide for matters connected therewith and incidental thereto.”
 
SOME SELECTED MINISTRY OF HEALTH MALAYSIA GUIDELINES / MANUALS RELATED TO HEALTH INFORMATION MANAGEMENT / MEDICAL RECORDS MANAGEMENT PRACTICES
1 INCIDENT REPORTING & LEARNING SYSTEM: “From Information to Action” Manual, January 2012
This manual maybe used by Health Information Management (HIM) / Medical Records (MR) practitioners to facilitate HIM / MR management to set up systems for identifying, reporting and managing “incidents” i.e. reportable events to provide a basis for which HIM / MR  practitioners concerned can review and further improve on their own event reporting system.
2 Pekeliling Ketua Pengarah Kesihatan Bil 17/2010 Garispanduan Pengendalian Dan Pengurusan Rekod Perubatan Pesakit Bagi Hospital-Hospital Dan Institusi Perubatan Kementerian Kesihatan Malaysia
A Ministry of Health Malaysia guideline in Malay (Bahasa Malaysia) on the practice and management of medical records for public hospitals and institutions issued through the Director General Health Circular No. 17/2010
3 Jadual Pelupusan Rekod Perubatan KKM MOHPAK121.06.(GU) Mac 2007
The standardised medical records retention and disposal schedule for all public hospitals and health facilities in Malaysia was circulated through a MoH circular MOH/PAK/121.06.(GU), Mac 2007 in March 2007 in Malay (Bahasa Malaysia).
 
WORLD HEALTH ORGANISATION (WHO) PUBLICATIONS
1 Medical Records Manual: A Guide for Developing Countries
A World Health Organisation (WHO) Regional Office for the Western Pacific publication “intended to help medical/health record workers in developing countries to develop and manage the medical record/health information service in an effective and efficient manner. It has been written for clerical staff with a basic understanding of medical/health record procedures and is designed to aid medical record officers (MROs) and medical record clerks by describing appropriate systems for Medical Record Departments.”
2 Electronic Health Records Manual for Developing Countries
A World Health Organisation (WHO) Regional Office for the Western Pacific publication “designed as a basic reference for use when exploring the development and implementation of Electronic Health Record (EHR) systems. It provides a general overview, some basic definitions and examples of EHR practices. Also covered are points for consideration when moving towards the introduction of an EHR, some issues and challenges which may need to be addressed and some possible strategies, along with steps and strategies to implementation.”
 
EDUCATIONAL MATERIALS AND BEST PRACTICE GUIDELINES
1 A compilation of educational modules for health records/health information management professionals around the world provided on the web site of the International Federation of Health Information Management Associations (IFHIMA). Go to the Learning Center page of the IFHIMA web site to access the educational modules.

Recent Posts

Voice-to-text medical software using NLP technology

When the doctor sits down with you on your visit, the doctor normally spends a lot of time inputting the how and the why of what’s happening to you, conventionally into a paper-based case note/medical record.

These free text narratives are further aggravated as not all doctors “speak the same way” in note creation and management.

These notes about your condition are rendered not easily extractable in ways that the data can be analyzed by a computer.

The good thing is this unstructured data of free text has given way to more and more ways to digital record-keeping—into the electronic health record systems (EHRs) way, away from the days of trying to decipher doctors’ medical lingo on hand written medical records and medical reports. However, EHRs are as unstructured patient data like its cousin, the paper-based medical record.

Inevitably, EHRs create challenges for doctors and that can be frustrating with additional data input responsibilities often bogged down by form-filling through the many clicks and screens required to navigate their EHRs, as well as they spending additional hours on updating EHRs.

EHRs became more important to be accurate and immediate with the scourge of the COVID-19 pandemic and with an increased reliance on contact-free consultations between doctors and patients.

Ultimately, huge volumes of unstructured patient data continue to be input into EHRs on a daily basis. As healthcare documentation is mostly unstructured, and it therefore goes largely unutilised, since mining and extraction of this data is challenging and resource intensive.

Medical Natural Language Processing (NLP) is steadily proving to be a solution to this challenge, creating new and exciting opportunities for healthcare delivery and patient experience. The adoption of NLP in healthcare is rising because of its recognized potential to search, analyze and interpret mammoth amounts of patient datasets.

Human beings use text and spoken words to fill up the human language with homonyms, homophones, sarcasm, idioms, metaphors, grammar and usage exceptions, variations in sentence structure, as some examples of ambiguities and irregularities as only they understand their usage.

NLP is a branch of artificial intelligence (AI) concerned with giving computers the ability to understand text and spoken words in much the same way we human beings can.

It is the main concept behind translation and personal assistance apps like Google Translate, OK Google, Siri, Cortana, and Alexa.

Without NLP technology using NLP healthcare tools capable of scrubbing large sets of unstructured health data, that data is not in a usable format for modern computer-based algorithms to easily access, extract, and accurately interpret clinical documentation of the actual patient record previously considered buried in text form.

NLP technology services accurately give voice to the unstructured data of the healthcare universe while processing the content of long chart notes of medical records, giving incredible insight into understanding quality, improving methods, and better results for patients that helps determine the disease burden and valuable decision support can be obtained.

Augnito is a voice-to-text medical software using NLP technology hoping  to improve healthcare, but for now specifically developed for the Indian market launched six months ago, and now being used in 24 States in India.

The voice has become the most powerful tool in technology today. Just by talking, the voice is the most natural way of communication for humans. We are able to do sophisticated and important jobs with gadgets like Alexa.

Like the Alexa gadget been able to do sophisticated and important jobs using voice controlled NLP technology, the Augnito software available for a monthly subscription on both Mac and Windows platforms, types out notes that are dictated to and saves it in an editable textual format on a cloud server.

The Augnito voice recognition software has a pre-programmed list of medical terms (its vocabulary database is constantly updated in keeping with doctors’ requirements and feedback), a built-in editor, report templates and keyboard shortcuts that help reduce repetitive typing.

Voice recognition software like Augnito using NLP technology, has the potential to boost a doctor’s productivity at a time of increased online consultations.

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