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PubMed2006

Nationally standardized electronic nursing documentation in Finland by the year 2007.

The electronic nursing documentation is not unified in Finland and it doesn't connect with nationally recommended multiprofessional core documentation of the patient history. The aims are to develop a nationally unified and standardized nursing documentation by the year 2007, to use the standardized nursing data to manage and assess the quality of the nursing process and to integrate the nursing documentation into the multiprofessional patient record. The nationally defined structured nursing documentation is piloted in 23 health care organizations during 2005-2007 by the support of the Ministry of Social Affairs and Health. Piloting covers special care, primary care and homecare. The nursing process is used as a structure for the documentation. The classification components of The Finnish Nursing Intervention Classification based on the Clinical Care Components developed in the United States by Dr. Virginia Saba provide the structure for documenting nursing care. Classification for outcomes and the core data for nursing summary will be developed. Finnish Oulu Patient Classification (OPC) is used to measure the patient care intensity.

Finland↗
PubMed1991

Effects of continuing education. Pain assessment and documentation.

Even though greater than 60% oncology patients experience pain sometime during the course of their illness, management of this pain still remains an enormous clinical problem. Based on this report, it would appear that pain assessment and management would be a key concern in the care of oncology patients. Yet, from previous research, it is clear that a lack of pain assessment documentation exists, which essentially means legally assessment has not been performed. Because a lack of knowledge about pain could be a major reason for inadequate pain documentation, a continuing education class was designed for oncology nurses regarding pain assessment and the need for subsequent documentation of that assessment. This study evaluated the different groups of nurses: (a) a control group who attended the class, (b) an experimental group who attended the class and received a laminated pain assessment tool, and (c) a group who did not participate in the class; effects on pain assessment documentation. Effectiveness was measured by extracting pain assessment documentation from charts. No significant differences in documentation scores were noted across the three groups. Recommendations and nursing implications concerning continuing education strategies and pain assessment documentation are made.

Education, Nursing, Continuing↗
PubMed1994

Using POSTDOC to recognize biomedical concepts in medical school curricular documents.

Recognition of the biomedical concepts in a document is prerequisite to further processing of the document: medical educators examine curricular documents to discover the coverage of certain topics, detect unwanted redundancies, integrate new content, and delete old content; and clinicians are concerned with terms in patient medical records for purposes ranging from creation of an electronic medical record to identification of medical literature relevant to a particular case. POSTDOC (POSTprocessor of DOCuments) is a computer application that (1) accepts as input a free-text, ASCII-formatted document and uses the Unified Medical Language System (UMLS) Metathesaurus to recognize relevant main concept terms; (2) provides term co-occurrence data and thus is able to identify potentially increasing correlations among concepts within the document; and (3) retrieves references from MEDLINE files based on user identification of relevant subjects. This paper describes a formative evaluation of POSTDOC's ability to recognize UMLS Metathesaurus biomedical concepts in medical school lecture outlines. The "precision" and "recall" varied over a wide range and were deemed not yet acceptable for automated creation of a database of concepts from curricular documents. However, results were good enough to warrant further study and continued system development.

Curriculum↗
PubMed1976

[Documentation in the hospital--methods and types of system (author's transl)].

Types of system and methods of documentation in clinic or hospital must be directed towards the object of the documentation: indexing or search documentation, informative or data documentation. Furthermore, a careful selection of the facts to be documented must be established, because a "complete clinical documentation" is unrealistic. Subtle knowledge of the methods of translation of medical facts into code numbers (coding techniques) is inevitable. Examples show how a very comprehensive data collection can be achieved in a short time from the documentation of only a few facts. Currently acquired data must be fed immediately for evaluation. The fact is criticized that some research promoters, when giving financial assistance for the installation of a data bank, shy away from providing the means for computer evaluation. In this way, useless "electronic data cemeteries" are produced. Consequently the demand, not only for the installation of data banks, but also to provide for their evaluation is deduced.

Diagnosis, Computer-Assisted↗
PubMed1996

Physicians' documentation of sexual abuse of children.

OBJECTIVES: To assess the quality of documentation by physicians in their evaluations for sexual abuse of children and to define factors that affect documentation. DESIGN: Cross-sectional survey and blinded chart review. SETTING: A statewide program for child abuse evaluations. PARTICIPANTS: Physicians (n = 145) who performed evaluations during fiscal year 1992-1993 were surveyed. Up to five randomly chosen medical records (n = 548), obtained from each eligible physician, were reviewed. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A survey of physicians who participated in the statewide program was made in summer 1993, with 78% participation. Knowledge scores were derived from the survey based on a comparison with the responses of a panel of five experts. Charts that were obtained from eligible physicians were assessed by two blinded reviewers. Documentation of the history and physical examination was evaluated as good or excellent by 30% and 23% of the physicians, respectively. Factors that were positively associated with better documentation of the history included a more structured format for the record, continuing medical education courses on sexual abuse of children, female gender, and a history of disclosure (P < .005 for all). Factors that were related to good documentation of the physical examination included structured records, continuing medical education courses, female gender, and knowledge scores. Factors that were not related to knowledge or documentation included the number of evaluations performed, practice group size or location, age of the physician, and a physician's reading of journal articles about sexual abuse of children. CONCLUSION: Quality of evaluations for sexual abuse of children may be improved by the use of structured records and participation in continuing medical education courses with regard to sexual abuse of children.

Adult↗
PubMedDate not supplied

Interdisciplinary documentation of patient education: how collaboration can effect change.

Changing healthcare trends are affecting all healthcare providers today, including those at Hillside Rehabilitation Hospital. Computerizing the interdisciplinary documentation of patient information was one change Hillside's leaders implemented to remain competitive and cost-effective. The benefits of moving from a handwritten documentation system to a computerized system were many. However, unforeseen difficulties with retrieving data became evident because the system was not developed to accommodate information about patient education. Through interdisciplinary collaboration, staff identified areas for improvement and made changes to the documentation process. They developed a "traveling card" for documenting patient education and then met a new set of challenges. The new documentation system met departmental and Joint Commission on Accreditation of Healthcare Organizations requirements for comprehensive patient education and documentation.

Cooperative Behavior↗
PubMed2001

The accuracy of medical record documentation in schizophrenia.

Medical records are commonly used to measure quality of care. However, little is known about how accurately they reflect patients' clinical condition. Even less is understood about what influences the accuracy of provider's documentation and whether patient characteristics impact documentation habits. Discrepancies between symptoms and side effects evaluated by direct assessment and medical records were examined for 224 patients with schizophrenia at two public mental health clinics. Multivariate regression was used to study the relationship between patient, provider, and treatment characteristics and documentation accuracy. Overall, documentation of symptoms and side effects was frequently absent. Documentation varied substantially between clinics, and it was generally less likely for patients who were severely ill, black, or perceived as noncompliant. The accuracy and consistency of medical record documentation should be demonstrated before using it to evaluate care at public mental health clinics.

Adolescent↗
PubMed2001

[Network of surgical wound centers using a new electronic data processing documentation system].

UNLABELLED: Care of chronic wounds is of enormous medical, social and economic importance. Nevertheless there is a lack of epidemiological and economical data. A network of ten wound care centers was created and data were documented in a new computerized wound documentation system. METHODS: Treatment was performed according to a comprehensive and standardized wound care protocol. The new documentation system is a network-capable solution. Digital images and planimetry as well as patient and wound related data are recorded. RESULTS: During the first year the ten centers treated and documented already 3281 wounds. There is a wide spectrum of different chronic wounds treated in the participating centers. Despite of long wound duration of several wounds with a median of 5 weeks (range 0-62 years), the healing rate was 80% within 455 days. CONCLUSION: Large amounts of data can be collected and scientifically evaluated in the wound net. This is realized by a new computerized documentation system, which was integrated into the clinical routine and enables clear and standardized documentation. Therefore even large multicenter therapy studies may be performed easily in the wound net and economical data could be collected.

Chronic Disease↗
PubMed2004

Factors impacting injury documentation after sexual assault: role of examiner experience and gender.

OBJECTIVE: This study was undertaken to determine whether physician gender or level of experience is associated with the prevalence of trauma documented in victims after sexual assault. STUDY DESIGN: All female patients 15 years or older reporting to an urban hospital with a complaint of sexual assault between January 1997 and September 1999 underwent a standardized history and physical examination by a second- or third-year resident in obstetrics and gynecology. Data were abstracted and verified. A chi(2) or Fisher exact test was used for categoric analysis. RESULTS: The overall prevalence of genital trauma was 21% in the 662 patients available for analysis. The prevalence of genital trauma documented by second- and third-year residents was 50 of 191 patients (26.2%) and 90 of 471 patients (19.1%), respectively (P=.04), despite similar assault characteristics between the 2 groups. The prevalence of genital trauma documented by male examiners (105/499 [21.0%]) and female examiners (35/160 [21.9%]) did not differ (P=.8). All examiners documented a similar prevalence of body trauma (52%). CONCLUSION: This study supports the hypothesis that the examiner's experience level may influence the prevalence of genital trauma documented after a sexual assault. Genital trauma documented was not associated with examiner gender in this study.

Adolescent↗
PubMed2005

Summarization from medical documents: a survey.

OBJECTIVE: The aim of this paper is to survey the recent work in medical documents summarization. BACKGROUND: During the last decade, documents summarization got increasing attention by the AI research community. More recently it also attracted the interest of the medical research community as well, due to the enormous growth of information that is available to the physicians and researchers in medicine, through the large and growing number of published journals, conference proceedings, medical sites and portals on the World Wide Web, electronic medical records, etc. METHODOLOGY: This survey gives first a general background on documents summarization, presenting the factors that summarization depends upon, discussing evaluation issues and describing briefly the various types of summarization techniques. It then examines the characteristics of the medical domain through the different types of medical documents. Finally, it presents and discusses the summarization techniques used so far in the medical domain, referring to the corresponding systems and their characteristics. DISCUSSION AND CONCLUSIONS: The paper discusses thoroughly the promising paths for future research in medical documents summarization. It mainly focuses on the issue of scaling to large collections of documents in various languages and from different media, on personalization issues, on portability to new sub-domains, and on the integration of summarization technology in practical applications.

Abstracting and Indexing↗
PubMed2006

Hip fracture documentation-the impact of shift systems.

The recent reduction in junior doctors' hours has lead to a change in working patterns. The aim of this study was to assess the effect of this change on documentation in orthopaedic surgery. Over a 6-week period, 25 patients were admitted to our unit with hip fractures. During this period, all junior doctors worked on a 'full-shift' working pattern. For comparison a control group was formed comprising of 29 patients admitted with hip fractures over an earlier 6 weeks when all junior doctors worked on a traditional 'on-call' system. The medical records of each patient were assessed for the quality of medical documentation using a published scoring system. The on-call group scored higher for the standard of documentation compared with the shift system group (mean 24.8 versus mean 21.3), p<0.05. The on-call group also had fewer weekdays without any documented entries in the medical records compared to the shift system group (mean 3.2 days versus mean 4.0 days), p<0.05. A change in the working pattern for junior doctors has lead to a reduction in the quality of medical documentation. With more personnel working fewer hours, maintaining a high standard of documentation is essential for the good clinical care of patients.

Aged↗
PubMed2004

Improving documentation of patient acuity level using a progress note template.

BACKGROUND: Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications. STUDY DESIGN: Surgical residents and patients on three inpatient services were followed for a 1-year prospective cohort study. After a 6-month baseline period, a progress note template was developed and implemented for 6 months, and administrative data were retrieved. Residents were given three case examinations assessing documentation knowledge pre- and postintervention, and a satisfaction survey. Demographics, Charlson comorbidity score, ICD-9 codes, template-specific ICD-9 codes, All Patient Refined (APR)-DRG patient severity, DRG relative weight, predicted mortality (University Healthcare Consortium), pre- and postexam scores, and resident satisfaction were collected. RESULTS: No difference in age, gender, race, or Charlson comorbidity score existed between pre- and postintervention patient groups. The length of stay decreased from 5.5 days to 4.8 days (p = 0.013). In the intervention group, total ICD-9 codes, template-specific ICD-9 codes, APR-DRG, DRG weight, and UHC predicted mortality had significant increases. Residents exposed to the progress note template improved their knowledge scores from 52% to 63% (p < 0.001), and 73% agreed that the progress note template was an improvement over handwritten notes. Residents not exposed to the progress note template did not improve their scores. CONCLUSIONS: A progress note template improves documentation of comorbidities and complications, APR-DRG patient severity for benchmarking, and case-mix index, and increases patient-specific predicted mortality. The progress note template also improves surgical residents' documentation knowledge and satisfaction.

Acute Disease↗
PubMed2004

A content analysis of forms, guidelines, and other materials documenting end-of-life care in intensive care units.

OBJECTIVE: The purpose of this study was to determine the extent to which data entry forms, guidelines, and other materials used for documentation in intensive care units (ICUs) attend to 6 key end-of-life care (EOLC) domains: 1) patient and family-centered decision making, 2) communication, 3) continuity of care, 4) emotional and practical support, 5) symptom management and comfort care, and 6) spiritual support. A second purpose was to determine how these materials might be modified to include more EOLC content and used to trigger clinical behaviors that might improve the quality of EOLC. PARTICIPANTS: Fifteen adult ICUs-8 medical, 2 surgical, and 4 mixed ICUs from the United States, and 1 mixed ICU in Canada, all affiliated with the Critical Care End-of-Life Peer Workgroup METHODS: Physician-nurse teams in each ICU received detailed checklists to facilitate and standardize collection of requested documentation materials. Content analysis was performed on the collected documents, aimed at characterizing the types of materials in use and the extent to which EOLC content was incorporated. MEASUREMENTS AND MAIN RESULTS: The domain of symptom management and comfort care was integrated most consistently on forms and other materials across the 15 ICUs, particularly pain assessment and management. The 5 other EOLC domains of patient and family centered decision-making, communication, emotional and practical support, continuity of care, and spiritual support were not well-represented on documentation. None of the 15 ICUs supplied a comprehensive EOLC policy or EOLC critical pathway that outlined an overall, interdisciplinary, sequenced approach for the care of dying patients and their families. Nursing materials included more cues for attending to EOLC domains and were more consistently preprinted and computerized than materials used by physicians. Computerized forms concerning EOLC were uncommon. Across the 15 ICUs, there were opportunities to make EOLC- related materials more capable of triggering and documenting specific EOLC clinical behaviors. CONCLUSIONS: Inclusion of EOLC items on ICU formatted data entry forms and other materials capable of triggering and documenting clinician behaviors is limited, particularly for physicians. Standardized scales, protocols, and guidelines exist for many of the EOLC domains and should be evaluated for possible use in ICUs. Whether such materials can improve EOLC has yet to be determined.

Attitude of Health Personnel↗
PubMed2006

Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services.

PURPOSE: Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care. METHODS: All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated. RESULTS: Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled 43,493 dollars. Critical care services were provided to 49 patients and yielded 8964 dollars in payments. Six hundred thirty-nine inpatient consultations were performed with a reimbursement of 42,830 dollars. Daily care services were billed 1044 times and produced 71,579 dollars in payments. Overall reimbursement for documented, nonoperative services was 166,866 dollars. This represented 16.2% of total, noncontracted income for the practice. CONCLUSION: Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial.

Child↗
PubMed1991

Documentation in the pediatric emergency department: a review of resuscitation cases.

STUDY OBJECTIVE: Documentation practices of staff physicians, residents, and nurses managing critically ill children were reviewed for completion of standard documentation requirements. DESIGN: Retrospective chart review. SETTING: Municipal children's hospital. PARTICIPANTS: 144 patients treated in the cardiopulmonary/trauma resuscitation room over a 17-month period. INTERVENTION: Emergency department records of these patients were reviewed for medical information required by Joint Commission on Accreditation of Healthcare Organizations guidelines: history of present illness, medical history, vital signs, physical examination, laboratory results, clinical observations, and diagnostic impression. In addition, the frequency of medical record review by legal representatives of the patient and by the state's social service agencies was evaluated. RESULTS: Attending physicians demonstrated more complete documentation than residents in clinical observations of patients (36.4% vs 18.0%, P less than .005) and diagnostic impression (97% vs. 78.4%, P less than .03). Nurses demonstrated more complete documentation than physicians, as a group, in laboratory results (83.9% vs 47.6%, P less than .001) and clinical observations (80.6% vs 22.2%, P less than .001). Sixty-six medical records (37.9%) were subjected to legal review: 37 (21.3%) by patients' legal representatives, and 29 (16.7%) by the state's social service agency. CONCLUSION: ED record documentation of pediatric patients treated in a cardiopulmonary/trauma resuscitation room often does not meet standard guidelines. Complete documentation is important due to the frequency of legal review of these records and the need to ensure post-ED continuity of care.

Documentation↗
PubMed2003

Documentation of ED patient pain by nurses and physicians.

The purpose of this study was to evaluate ED documentation of patient pain in light of the Joint Commission of Accreditation of Healthcare Organization's emphasis on pain assessment and management. A prospectively designed pain management survey was offered to patients on ED discharge. Documentation of pain intensity by ED nurses and physicians was retrospectively reviewed. Of 302 patients surveyed, 261 (86%) complete charts were available for review. Initial pain assessments were noted on 94% of the charts, but a pain scale was used for only 23% of the patients. Documentation of pain subsequent to therapy was noted on 39% of the charts, but a pain scale was used only 19% of the time. Subsequent to therapy, nurses were 2.2 x more likely to document pain assessments than physicians (30% vs 16%, P <.001). Patients with severe pain on arrival (46% vs 31%, odds ratio [OR] = 1.9, P <.02), chest pain (72% vs 32%, OR = 5.4, P <.001), or those receiving powerful analgesics (62% vs 32%, 3.5, P <.001) were more likely to receive a documented subsequent pain assessment than other patients. Pain severity is not consistently documented in ED patients, especially after therapy has been provided. Patients with severe pain and those receiving powerful analgesics were more likely to have a pain assessment subsequent to ED therapy.

Adult↗
PubMedDate not supplied

Documentation of decision-making during air transport.

INTRODUCTION: Decision-making is an integral part of quality patient care. The aim of this study was to evaluate decision-making documentation. METHODS: A retrospective descriptive design was used to examine the documentation for a convenience sample of 48 trauma patients transported by rotor-wing aircraft. RESULTS: A total of 1012 decisions were documented in the 48 records. The decisions were grouped into major conceptual problems. An average of 10.2 +/- 4.56 conceptual problems were identified in each record. The top 10 conceptual problems were evaluated. Adequate documentation was found to support all decision-making related to the top 10 problems. CONCLUSION: Although air medical personnel may not directly document statements of rationale for their decision-making, sufficient data were present in the records to support each documented decision.

Air Ambulances↗
PubMed2005

Cost-effectiveness analysis of medical documentation alternatives.

OBJECTIVES: The delay between patient discharge and the completion of the final discharge note have prompted hospitals to consider new information technologies. This study compared the relative cost-effectiveness of an automated medical documentation system to the current system in place at a Canadian hospital. There are significant expenditures associated with the choice of medical documentation system, yet the benefit to the patient population has not been studied. METHODS: A systematic review of the literature was carried out. Cost data for the current documentation system were obtained from the study hospital. The costs of purchasing the automated system were obtained from the manufacturer. Other resource cost implications of the automated system were estimated based on information obtained from the Centre for Applied Health Informatics at the study hospital. The outcome was determined to be the average time (days) between patient discharge and note completion. A cost-effectiveness analysis was conducted. Sensitivity analyses were used to determine the robustness of the results. RESULTS: The automated documentation system was associated with higher costs but better outcomes than the current system. The incremental cost-effectiveness ratio used for comparing the automated medical documentation system with the traditional system indicated that the incremental daily cost for decreasing a day in average note completion time per discharge note was 0.331 Canadian $/day over the study period (4 years). CONCLUSIONS: Although the automated documentation system was more expensive than the current system, it also provided qualitative benefits that were not considered in the cost-effectiveness analysis.

Automation↗