Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “DOCUMENTATION”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 235 records · Page 13Linked to original sources
PubMed1996

Source document position as it affects head position and neck muscle tension.

Measurements of head position, mechanical load at C7, and level of muscle EMG activity in the muscles of the neck were compared across six document positions in both a reading task and a typing (word processing) task. Source documents, identified as a primary visual task, were placed in two positions in front of the subject, flat on the table to each side of the keyboard, and on a document stand at each side of the keyboard. Each of the 20 subjects performed both a reading task and a typing task in each of these document positions while measurements were taken. It was found that the greatest variations in head position occurred in head rotation with documents flat on the table. This document position on each side also produced the greatest level of muscle tension in both the neck extensors and, to a lesser degree, the sternocleidomastoid muscles. In addition, greater variability between document position measures was found in the typing condition.

Adult↗
PubMed1995

Antenatal testing for HIV antibody: problems of documentation and record.

The objective of this study was to audit an ante-natal HIV screening programme by observing the congruence of documentation of consent between case notes and request forms; correlation of testing with prior agreement to be tested; and recording documentation that the test had been offered but declined in women who were not tested. The design was one of retrospective case note review of 538 women drawn from an inner city teaching hospital. There was documentation of invitation to undergo HIV testing in 415 (77%) cases. Test documentation was absent in 123 (23%) cases which represent 37% of those for whom a test was not performed. HIV testing was performed in 205 (38%) cases. There was discrepancy between documentation of consent to testing on the laboratory request form and in the notes. Some blood specimens of women agreeing to be tested were apparently never received in the laboratory. Incomplete documentation and a low test uptake suggests a low acceptance. However, without adequate documentation it cannot be determined in those not tested whether the test was declined or whether the invitation was either never extended, or not implemented after acceptance. Audit of implementation and staff compliance should be established at the outset of any universal testing programme.

Female↗
PubMed1999

Consent documents, reproductive issues, and the inclusion of women in clinical trials.

PURPOSE: To describe language used in consent documents at one academic medical center to inform women participating in studies of potential reproductive and fetal risks. METHOD: The authors reviewed consent document language describing reproductive and fetal risks in 114 approved protocols. Protocols were identified as being of high, low, or unknown risk based upon FDA drug-risk and radiation-risk categories. RESULTS: Although most consent documents advised women against participating for one or more pregnancy-related reasons, specific information about reproductive or fetal risks was included in fewer consent documents: 8 (73%) of the high-risk studies, 12 (40%) of the low-to-moderate-risk studies, and 29 (40%) of the unknown-risk studies. CONCLUSIONS: Investigators often omit fetal risk information from consent documents. Full disclosure of reproductive and fetal risks in consent documents and discussions can be taught and modeled during the research training period. The authors present a template with language that can be used in consent documents and recommend ongoing discussion of reproductive and fetal risks with women subjects throughout the study period.

Abnormalities, Drug-Induced↗
PubMed2004

Consent documents for oncology trials: does anybody read these things?

This study was conducted to assess the readability and length of informed consent documents used in clinical trials in oncology. One hundred seven consent documents from clinical protocols open to accrual at the Emory University Winship Cancer Institute were quantitatively analyzed. These included trials sponsored or organized internally, by commercial interests, and by various cooperative groups. Each form was analyzed using the electronic text version of the consent document approved by the Emory University IRB. Readability software was used to determine the length of each document and 2 measures of readability: The Flesch Reading Ease Score and a grade-level readability estimate using the Gunning Fog Index. The mean length +/- SD was 2709 +/- 971 words or 10.8 +/- 3.8 pages. The mean +/- SD Flesch Reading Ease Score was 45.48 +/- 5.24. The mean +/- SD grade level using the Gunning Fog Index was 11.9 +/- 1.53. None of the consent documents were written at or below the 8th-grade reading level; 1.8% were at or below the 9th-grade level; 10.5% were below the 10th-grade level. Results were similar regardless of study sponsor. Consent documents for clinical trials in oncology are lengthy and complex to the point that is unlikely that most patients will be willing to read them or be able to understand the concepts they discuss. IRBs and cooperative group review committees are either unwilling or unable to enforce widely accepted readability standards for the consent document. We discuss the implications of this situation and suggest ways to improve it.

Clinical Trials as Topic↗
PubMed2004

Content-based retrieval of historical Ottoman documents stored as textual images.

There is an accelerating demand to access the visual content of documents stored in historical and cultural archives. Availability of electronic imaging tools and effective image processing techniques makes it feasible to process the multimedia data in large databases. In this paper, a framework for content-based retrieval of historical documents in the Ottoman Empire archives is presented. The documents are stored as textual images, which are compressed by constructing a library of symbols occurring in a document, and the symbols in the original image are then replaced with pointers into the codebook to obtain a compressed representation of the image. The features in wavelet and spatial domain based on angular and distance span of shapes are used to extract the symbols. In order to make content-based retrieval in historical archives, a query is specified as a rectangular region in an input image and the same symbol-extraction process is applied to the query region. The queries are processed on the codebook of documents and the query images are identified in the resulting documents using the pointers in textual images. The querying process does not require decompression of images. The new content-based retrieval framework is also applicable to many other document archives using different scripts.

Abstracting and Indexing↗
PubMed2006

To what extent do geriatricians document the most bothersome symptoms of patients with advanced dementia?

OBJECTIVES: To assess whether geriatricians documented the bothersome symptoms of patients with advanced dementia, proxy reports of the most-bothersome symptoms affecting those patients (as elicited in research interviews) were compared with what geriatricians who had seen those patients in a proximate clinic visit documented in the medical record. DESIGN: Retrospective chart review. SETTING: Outpatient geriatrics clinic at the University of Chicago. PARTICIPANTS: Fifty-seven pairs of patients with dementia (Functional Assessment Staging Tool stage 6 or 7) and their proxies. MEASUREMENTS: Clinic notes were reviewed for documentation of patients' bothersome symptoms that proxies reported during research interviews. Proxy reports had been recorded in the previously established Palliative Excellence in Alzheimer Care Efforts database. RESULTS: The most-bothersome symptom was documented at least once in 84.2% (48/57) of clinic notes. The second-most-bothersome symptom was documented in 70.3% (26/37) of clinic notes. Most symptoms were documented in the Assessment and Plan section of the note. CONCLUSION: Geriatricians identified and documented the vast majority of bothersome symptoms, as reported by proxies, of patients with moderate to severe dementia.

Aged↗
PubMedDate not supplied

The HL7 Clinical Document Architecture.

Many people know of Health Level 7 (HL7) as an organization that creates health care messaging standards. Health Level 7 is also developing standards for the representation of clinical documents (such as discharge summaries and progress notes). These document standards make up the HL7 Clinical Document Architecture (CDA). The HL7 CDA Framework, release 1.0, became an ANSI-approved HL7 standard in November 2000. This article presents the approach and objectives of the CDA, along with a technical overview of the standard. The CDA is a document markup standard that specifies the structure and semantics of clinical documents. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. The document can be sent inside an HL7 message and can exist independently, outside a transferring message. The first release of the standard has attempted to fill an important gap by addressing common and largely narrative clinical notes. It deliberately leaves out certain advanced and complex semantics, both to foster broad implementation and to give time for these complex semantics to be fleshed out within HL7. Being a part of the emerging HL7 version 3 family of standards, the CDA derives its semantic content from the shared HL7 Reference Information Model and is implemented in Extensible Markup Language. The HL7 mission is to develop standards that enable semantic interoperability across all platforms. The HL7 version 3 family of standards, including the CDA, are moving us closer to the realization of this vision.

Computer Communication Networks↗
PubMed2002

Targeting of Asian Americans and Pacific Islanders by the tobacco industry: results from the Minnesota Tobacco Document Depository.

OBJECTIVE: The study objective was to review internal tobacco industry documents written between 1985 and 1995 regarding the Asian American and Pacific Islander (AAPI) population in the USA. These documents detail opportunities and barriers to promotion of tobacco products, as viewed by the tobacco industry and its market research firms. DATA SOURCES: /methods: Researchers reviewed tobacco industry documents from the document depository in Minneapolis, Minnesota and the tobacco industry's website, The Tobacco Archive, in a systematic fashion. A combined technique was employed using title keywords, dates, and names to search the 4(b) index. FINDINGS: A review of internal tobacco company documents reveal that during the late 1980s, the industry and its market research firms recognised the importance of the AAPI community as a potential business market. Documents describe the population growth in this community, the high prevalence of smoking in countries of origin, high purchasing power of AAPI immigrants, cultural predisposition to smoking, opportunities afforded by the high proportion of retail businesses under AAPI ownership, barriers to developing the AAPI market, comprehensive campaigns, and political and lobbying efforts. Comprehensive campaigns were designed to integrate promotion efforts in AAPI consumer, retail, and business communities. CONCLUSIONS: The documents show that the tobacco industry developed specific promotion strategies to target the AAPI population. Tobacco control initiatives in the AAPI group have been slower to develop than in other targeted ethnic groups, and may benefit by increased awareness of industry methods to promote tobacco use.

Advertising↗
PubMed2006

Consumer involvement in consent document development: a multicenter cluster randomized trial to assess study participants' understanding.

BACKGROUND: Despite widespread agreement on the importance of informed consent in clinical research, uncertainty remains about the adequacy of current consent procedures and documentation. METHODS: The objective of the study was to compare an informed consent document developed by a consumer group of potential study participants to one developed by the study investigators. The study was a cluster randomized, controlled study embedded in a 'parent' randomized controlled trial of 1092 participants with Gulf War veterans' illnesses recruited in 1999-2000 at 20 US medical centers. Centers were randomized to the investigator-developed or participant-developed consent document. The primary outcome measure was an Informed Consent Questionnaire-4 (ICQ-4), a validated four-item scale measuring self-reported participant understanding scored from 0 to 1. Secondary outcomes included the Client Satisfaction Questionnaire-8 and measures of study refusal and adherence to the parent trial protocol. RESULTS: There were no significant differences between consent documents on the ICQ-4 score overall or at any of the time points. Mean (95% CI) treatment differences ranged from +0.020 (-0.015, 0.055) (better understanding) at entry to -0.021 (-0.054, 0.012) (worse understanding) at three-months for the participant versus the investigator document group. There were also no significant differences in satisfaction, adherence to the protocol, or in the proportion of patients who refused to participate in the trial. LIMITATIONS: The consumer group may not have been representative of the study participants and they did not suggest dramatic changes to the consent document. The outcome assessment questionnaire was not validated prior to the trial's initiation. CONCLUSIONS: Consumer modification of the consent document did not lead to either benefit or harm in understanding, satisfaction, or study refusal and adherence rates. This study did demonstrate, however, that embedding consent studies in a clinical trial is feasible and can address important questions about informed consent without disrupting the primary study.

Adult↗
PubMed2005

HL7 Clinical Document Architecture, Release 2.

Clinical Document Architecture, Release One (CDA R1), became an American National Standards Institute (ANSI)-approved HL7 Standard in November 2000, representing the first specification derived from the Health Level 7 (HL7) Reference Information Model (RIM). CDA, Release Two (CDA R2), became an ANSI-approved HL7 Standard in May 2005 and is the subject of this article, where the focus is primarily on how the standard has evolved since CDA R1, particularly in the area of semantic representation of clinical events. CDA is a document markup standard that specifies the structure and semantics of a clinical document (such as a discharge summary or progress note) for the purpose of exchange. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. It can be transferred within a message and can exist independently, outside the transferring message. CDA documents are encoded in Extensible Markup Language (XML), and they derive their machine processable meaning from the RIM, coupled with terminology. The CDA R2 model is richly expressive, enabling the formal representation of clinical statements (such as observations, medication administrations, and adverse events) such that they can be interpreted and acted upon by a computer. On the other hand, CDA R2 offers a low bar for adoption, providing a mechanism for simply wrapping a non-XML document with the CDA header or for creating a document with a structured header and sections containing only narrative content. The intent is to facilitate widespread adoption, while providing a mechanism for incremental semantic interoperability.

Computer Communication Networks↗
PubMed1991

Documentation of client encounters by public health nurses at a county health department.

Documentation of high-risk infant (HRI) encounters in the nursing flowsheet by public health nurses (PHNs) at a county health department is evaluated for its effectiveness. A convenience sample of 31 client records was used. The effectiveness in documentation was evaluated in terms of PHNs' adherence to guidelines provided for the use of the particular nursing flowsheet. The frequency of correct documentation was determined for assessment, intervention, and outcome measures. Within the category of assessment, a high rate of correct documentation was found for the items, elimination, and bonding status. A moderate rate of correct documentation was noted for items pertaining to physical assessment, health-care system used, child abuse and neglect potential in the home, and safety. Documentation of anticipatory guidance or intervention provided was minimal throughout the flowsheet. The outcome measures, expressed as goal statements, were by comparison, more often documented correctly.

Forms and Records Control↗
PubMedDate not supplied

Nursing documentation: a program to promote and sustain improvement.

Pertinent, timely, and accurate nursing documentation promotes consistency in client care and effective communication among nurses and other health team members. Alternative documentation systems, continuing education efforts, and ongoing quality management activities are necessary to ensure that standards of record keeping are maintained. A pilot project using such methods was conducted on two hospital units to promote adherence to a specific documentation system. Education was integrated with peer auditing and follow-up over a 6-month period. The nursing staff significantly improved the quality of their documentation and sustained this improvement over time. Staff's knowledge about documentation improved significantly. Furthermore, there was a statistically significant decrease in documentation errors. The integration of peer auditing and continuing education enabled nurses to attain and maintain specific documentation standards.

Education, Nursing, Continuing↗
PubMed1997

Integration of a knowledge-based system and a clinical documentation system via a data dictionary.

This paper describes the design and realisation of a knowledge-based system and a clinical documentation system linked via a data dictionary. The software was developed as a shell with object oriented methods and C++ for IBM-compatible PC's and WINDOWS 3.1/95. The data dictionary covers terminology and document objects with relations to external classifications. It controls the terminology in the documentation program with form-based entry of clinical documents and in the knowledge-based system with scores and rules. The software was applied to the clinical field of acute abdominal pain by implementing a data dictionary with 580 terminology objects, 501 document objects, and 2136 links; a documentation module with 8 clinical documents and a knowledge-based system with 10 scores and 7 sets of rules.

Abdominal Pain↗
PubMed1999

[RHEUMexpert: a documentation and expert system for rheumatic diseases].

A computer assisted documentation of signs and findings in rheumatic diseases is described. This documentation was developed by the Austrian Society for Rheumatology and thought to be a minimal standard for the use by general practitioners. In addition, a knowledge-based basic differential diagnosis support was developed, which differentiates between major groups of rheumatic diseases as inflammatory spine diseases, mechanical or metabolic reasons for spine disorders, inflammatory joint diseases, degenerative or metabolic joint diseases, soft tissue diseases. This presentation describes the results of an evaluation of 75 typical case histories and a second study where 252 case histories were documented retrospectively in this new system. The results of the first showed a pretty good discrimination between the described groups of different diagnoses (sensitivity between 71 and 100 percent for all groups with the exception of metabolic joint diseases, specificity between 75 and 94 percent). The second--retrospective--documentation and diagnostic support showed much weaker results (sensitivity for major groups 74-76 percent). The reasons for the different outcomes are discussed: On the one hand, signs and symptoms from case reports could not be transferred completely in the new documentation, as some findings retrospectively could not be defined sharp enough. On the other hand the study showed, that the sensitivity of well defined disorders as inflammatory joint diseases (exp. rheumatoid arthritis) reaches almost 100 percent, whereas it is as low as 50 percent in some other diseases (e.g. gout) whose characteristic findings and symptoms are suppressed by treatment (drug medication) in many cases. The results show that computer based documentation of rheumatic diseases facilitates the systematized and standardised documentation of patient data. However, a few modifications of the knowledge base as well as the knowledge representation formalisms are necessary to achieve a better performance in differential diagnostic support.

Arthritis, Rheumatoid↗
PubMedDate not supplied

Medication review and documentation in physician office practice.

CONTEXT: Adverse drug reactions and drug-drug interactions are common. Medication-induced morbidity might be prevented through the documentation of medicines in the medical record and review of the medical record before new medications are prescribed. PRACTICE PATTERN EXAMINED: Documentation and review by primary care physicians of patient use of prescription drugs, over-the-counter drugs (OTCs), nutritional supplements, and herbal and other alternative treatments. DATA SOURCE: A stratified random sample of 1802 internists and family practitioners from the American Medical Association Physician Masterfile was surveyed; 655 physicians responded (response rate, 36%). RESULTS: 99.8% of physicians reported documenting prescription drugs in the medical record. Fewer reported documenting OTCs (68%) or nutritional supplements (63%); only 47% documented herbal and other alternative treatments. Almost all respondents reported reviewing prescription medications before prescribing a new therapy (99.8%), but only 86% reported reviewing OTCs at the same time. Fewer than half of physicians reported reviewing nutritional supplements or herbal and other alternative treatments before prescribing a new therapy. CONCLUSIONS: This study draws on self-reported data, and the response rate was low. Thus, the results probably overestimate actual rates of documentation and review. Review and documentation of nonprescription substances are uncommon in primary care practice.

Dietary Supplements↗
PubMed2003

The diagnosis and treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology.

This International Society of Lymphology (ISL) Consensus Document is the current revision of the 1995 Document for the evaluation and management of peripheral lymphedema. It is based upon modifications suggested and published following the 1997 XVI International Congress of Lymphology (ICL) in Madrid, Spain, discussed at the 1999 XVII ICL in Chennai, India, considered at the 2000 (ISL) Executive Committee meeting in Hinterzarten, Germany, and derived from integration of discussions and written comments obtained during and following the 2001 XVIII ICL in Genoa, Italy as modified at the 2003 ISL Executive Committee meeting in Cordoba, Argentina. The document attempts to amalgamate the broad spectrum of protocols advocated worldwide for the diagnosis and treatment of peripheral lymphedema into a coordinated proclamation representing a "Consensus" of the international community. The document is not meant to override individual clinical considerations for problematic patients nor to stifle progress. It is also not meant to be a legal formulation from which variations define medical malpractice. The Society understands that in some clinics the method of treatment derives from national standards while in others access to medical equipment and supplies is limited and therefore the suggested treatments are impractical. We continue to struggle to keep the document concise while balancing the need for depth and details. With these considerations in mind, we believe that this version of the Consensus represents the best judgment of the ISL membership on how to approach patients with peripheral lymphedema as of 2003. We anticipate that the document will and should be challenged, debated in the pages of Lymphology (e.g., as Letters to the Editor), and ideally become a continued focal point for robust discussion at local, national and international conferences in lymphology and related disciplines. We further anticipate as experience evolves and new ideas and technologies emerge that this "living document" will undergo periodic revision and refinement.

Biopsy↗
PubMed2005

MorphoSaurus--design and evaluation of an interlingua-based, cross-language document retrieval engine for the medical domain.

OBJECTIVES: We propose an interlingua-based indexing approach to account for the particular challenges that arise in the design and implementation of cross-language document retrieval systems for the medical domain. METHODS: Documents, as well as queries, are mapped to a language-independent conceptual layer on which retrieval operations are performed. We contrast this approach with the direct translation of German queries to English ones which, subsequently, are matched against English documents. RESULTS: We evaluate both approaches, interlingua-based and direct translation, on a large medical document collection, the OHSUMED corpus. A substantial benefit for interlingua-based document retrieval using German queries on English texts is found, which amounts to 93% of the (monolingual) English baseline. CONCLUSIONS: Most state-of-the-art cross-language information retrieval systems translate user queries to the language(s) of the target documents. In contra-distinction to this approach, translating both documents and user queries into a language-independent, concept-like representation format is more beneficial to enhance cross-language retrieval performance.

Abstracting and Indexing↗
PubMedDate not supplied

[Interrelationship among "NANDA, NOC and NIC". A pilot study and an evaluation of a nursing document].

OBJECTIVES: (a) to determine the effectiveness of a nursing document which integrates nursing diagnoses, nursing treatments/actions (NIC), and results (NOC); (b) to verify the application of the aforementioned document in a hospitalization unit. MATERIALS AND METHODS: A descriptive, transversal and observational study. MATERIALS: Nursing documents (NANDA, NIC and NOC taxonomies). PHASES: 1st: analysis of the content in the nursing documentation for 23 pneumonic patients: Selection of nursing diagnoses and the most frequent interdependent problems. 2nd: Selection of results and nursing treatment/actions. 3rd: Elaboration of the document and a description of the Likert scales to define the state of the indicators for each result. 4th: A pilot study of the document applied to 12 patients. CONCLUSIONS: the application of the document permits one to identify the real status of a patient; to establish specific objectives; to improve the recording of data; to observe the effectiveness of treatment; to include educational activities; to give greater continuity and quality to a treatment plan.

Cross-Sectional Studies↗