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At least 199 records · Page 11Linked to original sources
PubMed1999

[Evaluation of standardized routine documentation with implementation of the requirements of multicenter studies. Presentation on the example of a knee endoprosthesis].

In 1988 we did develop an EDP-System for data collection of daily routine documentation, which allows on the one hand a complete registration and on the other hand only offers entire and plausible data because of the logical program structure. The registered data are saved in a data bank structure as well as in report form for routine documentation. The substitution of routine documentation by such a system essentially depends on the content of interrogation which has to reflect the user's individual indication and operative technique. First doubts about reflection of the high variation of the individual operative technique could be disproved with help of the evaluation of this system of documentation. None of the 200 registered cases had to be documented without the help of the standardized system. The use in a prospective multicenter study for endoprosthesis of the knee was the starting point of the evaluation for the system's efficiency and acceptance. It had been analyzed the expressiveness of the study's documentation. As there was no standard in free dictated operation records the information content seemed to be reduced and with regard to scientific aspects unqualified. The analysis of the EDP-system especially checked three aspects: the general suitability to represent medical facts by standardized evaluation as well as the user's and patient's acceptance. All in all this system is an instrument for standardized daily routine documentation in a clinic which seems able to establish a quality management because of the high data quality, the differentiated registrations of multiple parameters and timeneutral application.

Arthroplasty, Replacement, Knee↗
PubMed2006

Cognitive factors influencing perceptions of clinical documentation tools.

Identifying healthcare providers' perceptions of clinical documentation methods can inform the design of computer-based documentation tools. The authors investigated the cognitive factors underlying such perceptions by performing a qualitative analysis that included open-ended in-depth interviews of a convenience sample of healthcare providers who use a variety of documentation methods. A total of 16 providers participated in the study; subjects included physicians and nurse practitioners from medical and surgical specialties who used paper- and computer-based documentation tools. Based on interview data, authors identified five factors that influenced satisfaction with clinical documentation tools: document system time efficiency, availability, expressivity, structure, and quality. These factors, if validated by subsequent investigations, can be used to develop a formal conceptual model of providers' perceptions of their satisfaction with various documentation systems.

Adult↗
PubMedDate not supplied

Review of initiatives adopted for effective documentation of torture in a developing country.

Effective documentation of torture is the key to successful interrogation and redress of torture victims. However the facilities available for such documentation to the forensic practitioners in less resourced countries are far from satisfactory. The emphasis on accurate and detailed documentation of examination findings of torture victims is currently necessary in Sri Lanka as the courts are relying heavily on medical reports for interrogation. In a situation where most of the torture victims are examined by unskilled medical officers who are not full time forensic practitioners, deficiencies of various degrees are commonly observed pertaining to depth of examination and documentation of examination findings. Therefore it was attempted in 2004, to introduce uniformity to existing documentation procedures by implementing Istanbul Protocol on island wide basis. However it was revealed that the adoption of the Istanbul Protocol could not be done as a whole in a short period due to variable degree of compliance from medical officers and further it need to be modified according to domestic requirements. The documentation of torture is a distinct multistage and multidisciplinary process. Therefore unless and until a cohesive collaboration is established between all disciplines concerned, a positive development on documentation process cannot be anticipated.

Data Collection↗
PubMed2000

Perioperative documentation in Finland.

In Finland, research studies about perioperative documentation are few, and there are no professional recommendations for perioperative documentation, such as AORN s Standards, Recommended Practices, and Guidelines. Exploring current documentation practices and contents used in Finland is the first step to establishing a standard for perioperative documentation. The need for this type of exploration resulted in a study that found that the aim of nursing documentation is not always clear, and current documentation practice does not necessarily reveal the decision making that directs patient care, demonstrate nursing resources needed, or provide data for evaluating and developing perioperative practice. Education, motivation, and computerization generally were mentioned as a means to develop documentation.

Documentation↗
PubMed1992

Preformatted charts improve documentation in the emergency department.

STUDY OBJECTIVES: To determine if the use of programmed charts with complaint-specific entry criteria results in improved documentation of patient encounters and better clinical outcome. DESIGN: Prospective study. SETTING: Emergency department of an urban university hospital. TYPE OF PARTICIPANTS: Female patients presenting to the emergency department with gynecologic complaints of abdominal pain, bleeding, or vaginal discharge. INTERVENTIONS: Programmed and blank charts were provided randomly for physicians in the ED. MEASUREMENTS: Chart scores based on documentation criteria for patient history, physical examination, laboratory studies, diagnosis, and discharge instructions and patient outcome scores of 0% to 100% based on the persistence of their complaints at the time of the follow-up interview. MAIN RESULTS: Overall documentation of history, physical examination, and laboratory studies was more complete on programmed charts than on blank charts (81.1% vs 71%, P less than .0001). The patient history portion of the charts was found to benefit the most from the use of programmed charts (74.8% vs 60.1%, P less than .0001). Although programmed charts demonstrated better documentation, there was no statistically significant correlation with patient outcome parameters or with patient satisfaction with the quality of medical care. However, more patients whose physicians used programmed charts were satisfied with their physicians' explanations of their problem (chi 2 = 5.2, P less than .02). CONCLUSION: Programmed charts improve documentation by facilitation of the documentation process and allow more time for patient-physician interaction. Quality of documentation alone, however, is not a reliable indicator of patient outcome or of the quality of care received.

Abdominal Pain↗
PubMed2001

[Development and integration of the Oncological Documentation System ODS].

PURPOSE: To simplify clinical routine and to improve medical quality without exceeding the existing resources. Intensifying communication and cooperation between all institutions of patients' health care. The huge amount of documentation work of physicians can no longer be done without modern tools of paperless data processing. METHODS: The development of ODS was a tight cooperation between physician and technician which resulted in a mutual understanding and led to a high level of user convenience. - At present all cases of gynecology, especially gynecologic oncology can be documented and processed by ODS. Users easily will adopt the system as data entry within different program areas follows the same rules. In addition users can choose between an individual input of data and assistants guiding them through highly specific areas of documentation. RESULTS: ODS is a modern, modular structured and very fast multiuser database environment for in- and outpatient documentation. It automatically generates a lot of reports for clinical day to day business. Statistical routines will help the user reflecting his work and its quality. Documentation of clinical trials according to the GCP guidelines can be done by ODS using the internet or offline datasharing. CONCLUSIONS: As ODS is the synthesis of a computer based patient administration system and an oncological documentation database, it represents the basis for the construction of the electronical patient chart as well as the digital documentation of clinical trials. The introduction of this new technology to physicians and nurses has to be done slowly and carefully, in order to increase motivation and to improve the results.

Clinical Trials as Topic↗
PubMed2004

[A multidisciplinary mModule for oncological documentation within a hospital information system].

The follow-up documentation of oncological patients in Germany is inadequate in many cases: it is usually limited to a minimal dataset mandated by the epidemiological tumor registers; it is carried out in a paper-based fashion and rarely in a multi-disciplinary context. Parallel documentation efforts can result in redundant or erroneous data and excess work. The introduction of hospital information systems (HIS) allows the implementation of digital oncological documentation systems integrated in surrounding clinical workflows that can provide access to existing data sources as well as data entry and presentation across departmental boundaries. This concept enables the integration of tumor documentation, quality assurance and process optimization within HIS. Feasibility requirements include a high flexibility and adaptability of the underlying HIS to reach a seamless integration of oncological documentation forms within routine clinical workflows. This paper presents the conceptual design and implementation of a modular oncological documentation system at the Muenster University Hospital that is capable of integrating the documentation requirements of multiple departments within the hospital.

Computer Systems↗
PubMed1991

Remembering about documents: memory for appearance, format, and location.

If we remember the visual appearance of documents, and other attributes such as location, then a number of new information management strategies become possible candidates for application in the design of filing systems. This paper describes a number of experiments aimed at investigating aspects of memory for documents in office settings. There is no evidence, as has previously been suggested, that automatic encoding for appearance or location of documents occurs at significant levels. The results of these experiments are more consistent with the view that visual and spatial attributes of documents are remembered in proportion to the attention paid to them when the documents are handled. The experiments also illustrate the sensitivity of this principle to the context in which subjects use documents. It is apparent that office tasks vary considerably in the extent to which subjects must pay attention to the visual and locational attributes of the documents handled. The consequences for the design of filing systems is discussed in terms of what methods for storage and retrieval can usefully be built into the design of systems.

Attention↗
PubMed2001

Policies on documentation and disciplinary action in hospital pharmacies after a medication error.

Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.

Documentation↗
PubMed2003

Documenting pharmacist interventions on an intranet.

The process of developing and implementing an intranet Web site for clinical intervention documentation is described. An inpatient pharmacy department initiated an organizationwide effort to improve documentation of interventions by pharmacists at its seven hospitals to achieve real-time capture of meaningful benchmarking data. Standardization of intervention types would allow the health system to contrast and compare medication use, process improvement, and patient care initiatives among its hospitals. After completing a needs assessment and reviewing current methodologies, a computerized tracking tool was developed in-house and integrated with the organization's intranet. Representatives from all hospitals agreed on content and functionality requirements for the Web site. The site was completed and activated in February 2002. Before this Web site was established, the most documented intervention types were Renal Adjustment and Clarify Dose, with a daily average of four and three, respectively. After site activation, daily averages for Renal Adjustment remained unchanged, but Clarify Dose is now documented nine times per day. Drug Information and i.v.-to-p.o. intervention types, which previously averaged less than one intervention per day, are now documented an average of four times daily. Approximately 91% of staff pharmacists are using this site. Future plans for this site include enhanced accessibility to the site with wireless personal digital assistants. The design and implementation of an intranet Web site to document pharmacists' interventions doubled the rate of intervention documentation and standardized the intervention types among hospitals in the health system.

California↗
PubMed1995

Childhood injuries and the importance of documentation in the emergency department.

The purpose of this study is 1) to evaluate the extent to which documentation of the medical record is completed for dependent children who present for evaluation of an acute injury, and 2) to examine the factors that favorably or adversely influence completion of the medical record. The emergency department (ED) ledgers of 669 children less than nine years of age were reviewed, including 172 (25.7%) who presented for evaluation of an acute injury. Each of the latter charts was examined for basic demographic data, as well as information about injury type and mechanism, ED provider, and involvement of social services personnel. The ledgers were further examined to determine completeness of chart documentation in several relevant areas, including the circumstances and characteristics of the acute injury, pertinent past medical history, and course of management and referral while in the ED. Each of 15 individual documentation variables was assigned a score of either zero (incompletely/not addressed or documented) or one (completely addressed or documented). The 15 individual scores were equally weighted and summed, resulting in a total documentation score ranging from zero (failure to address or document any of the 15 variables) to 15 (all variables completely addressed/documented). The mechanisms of injury included falls from height (48.3%), direct blunt impact other than falls (26.7%), penetrating injury (6.4%), burn (5.2%), and ingestion (8.1%). Seventeen patients (9.9%) were admitted for primarily medical, and one (0.6%) for primarily social, indications; one patient died as a result of his injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗
PubMed2006

Font adaptive word indexing of modern printed documents.

We propose an approach for the word-level indexing of modern printed documents which are difficult to recognize using current OCR engines. By means of word-level indexing, it is possible to retrieve the position of words in a document, enabling queries involving proximity of terms. Web search engines implement this kind of indexing, allowing users to retrieve Web pages on the basis of their textual content. Nowadays, digital libraries hold collections of digitized documents that can be retrieved either by browsing the document images or relying on appropriate metadata assembled by domain experts. Word indexing tools would therefore increase the access to these collections. The proposed system is designed to index homogeneous document collections by automatically adapting to different languages and font styles without relying on OCR engines for character recognition. The approach is based on three main ideas: the use of Self Organizing Maps (SOM) to perform unsupervised character clustering, the definition of one suitable vector-based word representation whose size depends on the word aspect-ratio, and the run-time alignment of the query word with indexed words to deal with broken and touching characters. The most appropriate applications are for processing modern printed documents (17th to 19th centuries) where current OCR engines are less accurate. Our experimental analysis addresses six data sets containing documents ranging from books of the 17th century to contemporary journals.

Abstracting and Indexing↗
PubMed2004

Electronic nursing documentation in primary health care.

The aim of this study was to describe and analyse nursing documentation based on an electronic patient record (EPR) system in primary health care (PHC) with emphasis on the nurses' opinions and what, according to the nursing process and the use of the keywords, the nurses documented. The study was performed in one county council in the south of Sweden and included 42 Primary Health Care Centres (PHCC). It consisted of a survey, an audit of nursing records with the Cat-ch-Ing instrument and calculation of frequencies of keywords used during a 1-year period. For the survey, district nurses received a postal questionnaire. The results from the survey indicated an overall positive tendency concerning the district nurses' opinions on documentation. Lack of in-service training in nursing documentation was noted and requested from the district nurses. All three parts of the study showed that the keywords nursing interventions and status were frequently used while nursing diagnosis and goal were infrequent. From the audit, it was noted that medical status and interventions appeared more often than nursing status. The study demonstrated limitations in the nursing documentation that inhibited the possibility of using it to evaluate the care given. In order to develop the nursing documentation, there is a need for support and education to strengthen the district nurses' professional identity. Involvement from the heads of the PHCC and the manufactures of the EPR system is necessary, in cooperation with the district nurses, to render the nursing documentation suitable for future use in the evaluation and development of care.

Adult↗
PubMed1997

Readability of advance directive documents.

PURPOSE: To assess the readability of advance directive documents. DESIGN: Descriptive. SAMPLE: Convenience, 10 advance directive documents from various sources. METHODS: Advance directive documents were electronically scanned in 1994 then evaluated using three readability formulas: Flesch-Kincaid Grade Level, Flesch Reading Score, and Gunning's Fog Index. FINDINGS: The average readability (in school grade levels) of the 10 documents was 11.3 using the Flesch-Kincaid Grade Level and 18.2 using the Gunning's Fog Index. CONCLUSIONS: All documents were above reading levels usually recommended for patients. CLINICAL IMPLICATIONS: Patients must be able to read and understand advance directive documents before signing them. Refinement of the documents is recommended to support patient understanding and autonomy in end-of-life care.

Advance Directives↗
PubMed2002

Tobacco industry documents: comparing the Minnesota Depository and internet access.

OBJECTIVE: To assess the comparability of searches conducted on two publicly available tobacco industry document collections: hard copies housed and maintained by a neutral party in the Minnesota Depository and electronic copies available through tobacco industry maintained websites. METHODS: We conducted a set of searches in Minnesota and then conducted the same searches using the industry websites. We matched documents by Bates number, weeded out duplicates, and coded documents that were unique to either collection as major, minor, or trivial. RESULTS: Among hundreds of documents produced by several searches, we found only four unique major documents in the Minnesota Depository. By contrast, we found 62 unique major documents using the websites. CONCLUSION: These results suggest that researchers can rely on industry websites while waiting for improved access resulting from searching, indexing, and document storage administered by the tobacco control community. Searching the tobacco industry websites is at least as good as searching in Minnesota and may in some instances actually be better. Four smaller subcollections, however, can only be searched by hand in Minnesota.

Databases, Factual↗
PubMed1998

Psychiatrists' documentation of informed consent.

OBJECTIVE: The present study was undertaken to determine current attitudes and behaviour toward informed consent for antipsychotic medication and documentation of the informed consent process in patient charts. METHOD: Thirty psychiatrists treating a minimum of 10 patients on antipsychotic medication were selected from teaching and nonteaching hospitals. Clinicians completed questionnaires on their behaviour and attitudes regarding documentation of informed consent and antipsychotic medication. Physicians' charts were reviewed to ascertain documentation. RESULTS: Psychiatrists reported sometimes documenting the informed consent process. The chart review revealed that, on average, each psychiatrist had documentation in 23% of charts. Physicians who either were affiliated with a teaching hospital or spent more time reading medical journals were more likely to document the informed consent process. CONCLUSIONS: Physicians who use antipsychotic medication as a treatment in their practice are not routinely documenting the informed consent process in patient records. Physicians should pay more attention to this aspect of record keeping because it is their only record of the consent process.

Adult↗
PubMedDate not supplied

Documentation of clinical interventions by pharmacy faculty, residents, and students.

OBJECTIVE: To describe the influence of pharmacy faculty, residents, and students at a community hospital by documenting the number and types of interventions attributable to their involvement in patient-care activities. METHODS: Between September 1, 1997, and May 31, 1999, data were collected using a computerized documentation system to characterize the intervention type, significance, and value of services rendered by an education group composed of pharmacy faculty (n = 2), residents (n = 4), and students (n = 22). RESULTS: The number, nature, and outcome category for all interventions were documented using an existing computerized documentation system. The education group accounted for 13% (n = 2,873) of total clinical activities documented (n = 21,817). The most common activities reported were discharge counseling/education (31%), consultation by physicians and therapeutic recommendations (15%), and route conversion (6%). Interventions documented by the education group were classified as medium or high significance 50% of the time. Sixteen percent ($172,655) of the estimated cost avoidance documented by the pharmacy department was attributed to the education group. CONCLUSIONS: This study demonstrates that educational activities by pharmacy faculty, residents, and students have a positive influence on patient care in a community hospital.

Alabama↗
PubMed2003

Practice variation in respiratory therapy documentation during mechanical ventilation.

STUDY OBJECTIVES: Implementation of new ventilatory strategies such as lung-protective ventilation for ARDS will require a multidisciplinary approach with considerable physician and respiratory therapy (RT) interaction. One of the key factors in this communication is complete and accurate RT documentation of ventilator settings. Few studies have explored the quality and variability of this documentation. DESIGN: Population-based cross-sectional study. SETTING: Seventeen adult hospitals in King County, WA. PARTICIPANTS/INTERVENTIONS: We compared the blank RT ICU flow sheet for each institution to the 1992 American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) for patient-ventilator system checks. We interviewed RT managers at each hospital about their practices. Finally, we reviewed selected charts of patients with acute lung injury (ALI) or ARDS from each hospital to evaluate the documentation. MEASUREMENTS/RESULTS: We found substantial variability in RT documentation practices and in their extent of compliance with the AARC CPGs. Only 15 of 52 items recommended by the AARC CPGs were included on blank RT flow sheets of every hospital in our study, and only 26 of 52 items were found on charts of ALI/ARDS patients at most hospitals (ie, > or =10 of 17 hospitals). Only 10 of 17 RT department managers reported using the AARC CPGs as a basis for their documentation policies. Items necessary for the implementation of lung-protective ventilation for ALI/ARDS patients were recorded inconsistently and were not included in the AARC CPGs. Plateau pressure was found on all reviewed charts of ALI/ARDS patients at only 10 of 17 hospitals. CONCLUSIONS: Considerable variability exists in RT documentation practices. We suggest that new guidelines be developed for documenting the care of patients receiving mechanical ventilation, in light of recent data on ventilator weaning and the management of ALI/ARDS, and that their effect on practice and outcomes be evaluated.

Cross-Sectional Studies↗