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At least 289 records · Page 16Linked to original sources
PubMed2005

Improving documentation of head injured patients admitted to the emergency department ward.

OBJECTIVE: Well-written and factually accurate medical records are one of the cornerstones of Emergency Medicine. This audit aimed to assess whether documentation could be improved for head injured patients admitted to the Emergency Department observation ward using a pre-printed proforma. METHODS: In the first phase the notes of a consecutive series of forty patients admitted for observation to an Emergency Department ward after sustaining a head injury were prospectively audited. A data collection instrument was designed to measure the presence or absence of documentation of mechanism of injury, specific symptoms, signs, medications, investigations and treatment considered essential for gold standard head injury management. In the second phase a specially designed proforma was introduced for all patients being admitted for observation. The notes of a second consecutive series of forty patients were then audited using the same data collection instrument. RESULTS: The first phase of the audit revealed inadequate documentation with regard to many of the measured variables. Significant Improvements were noted in all measured variables after the introduction of the proforma. CONCLUSIONS: Documentation of all important positive and negative signs in head injured patients can be time consuming and often a challenge for doctors working in busy Emergency Departments. Accurate documentation is however important from both a clinical and a medico-legal position and this audit have shown that the introduction of a customized proforma can improve the quality of documentation. In addition clinical management of head injured patients may improve as the proforma also acts as a prompt for their subsequent investigation and treatment.

Craniocerebral Trauma↗
PubMed2006

Responsiveness of the International Knee Documentation Committee Subjective Knee Form.

BACKGROUND AND PURPOSE: The International Knee Documentation Committee Subjective Knee Form was developed to measure change in symptoms, function, and sports activity in patients treated for a variety of knee conditions. Although previous research has demonstrated reliability and validity of the form, its responsiveness has not been evaluated. The purpose of this study was to determine responsiveness of the International Knee Documentation Committee Subjective Knee Form. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: Patients who participated in the original validation study for the International Knee Documentation Committee Subjective Knee Form completed the form and a 7-level global rating of change scale that ranged from greatly worse to greatly better after a mean of 1.6 years (range, 0.5-2.3 years). Analyses included calculation of the standardized response mean and mean change in International Knee Documentation Committee Subjective Knee Form score compared to the patient's perception of change on the global rating of change scale. In addition, a receiver operating characteristic curve was plotted to determine the change in score that best distinguished patients who improved from those who did not. RESULTS: The overall standardized response mean was 0.94, which is considered large. With the exception of those who were slightly worse or unchanged, the mean change in the International Knee Documentation Committee Subjective Knee Form score compared to the patients' perceived global ratings of change was as expected (greatly worse, -15.1; somewhat worse, -8.4; slightly worse, 20.6; no change, 10.7; slightly better, 5.9; somewhat better, 18.1; greatly better, 38.7). The receiver operating characteristic curve analysis revealed that a change score of 11.5 points had the highest sensitivity, and a change score of 20.5 points had the highest specificity to distinguish between those who were or were not improved. CONCLUSION: The International Knee Documentation Committee Subjective Knee Form is a responsive measure of symptoms, function, and sports activity for patients with a variety of knee conditions.

Adolescent↗
PubMed2006

Psychiatrists' documentation of informed consent: a representative survey.

OBJECTIVE: To review psychiatrists' documentation of informed consent and present data on Canadian psychiatrists' attitudes and practices regarding documentation of the informed consent process. METHOD: We surveyed a stratified random sample of psychiatrists practising in Ontario, using a mailed self-report questionnaire. RESULTS: The response rate was 72%. Among respondents, 63% routinely documented the consent process, with younger respondents reporting more documentation than older ones. Although most respondents (77%) favoured recording the consent process, only 11% felt signed consent forms were necessary. CONCLUSION: There are differences in the self-reported documentation behaviour of younger and older psychiatrists. Psychiatrists should document the consent process in the clinical record.

Adult↗
PubMed2004

Evaluating the impact of an educational intervention on documentation of decision-making capacity in an emergency medical services system.

OBJECTIVES: To compare the documentation of decision-making capacity by advanced life support (ALS) providers and signature acquisition before, one month after, and one year after an educational intervention. METHODS: The intervention comprised a one-and-a-half-hour module on assessment and documentation of decision-making capacity. Ambulance call reports were reviewed for all ALS calls occurring during three two-month periods, and refusals of transport were recorded. Provider compliance with documentation of decision-making capacity and signature acquisition were determined from a convenience sample of 75 reports from each period. Reviewers were blinded to study period. Twenty-percent double data entry was undertaken to evaluate accuracy. Ninety-five percent confidence intervals were calculated to compare frequencies of cancelled calls and documentation. RESULTS: From the emergency medical services database, 7,744 calls before the intervention, 7,444 immediately after, and 7,604 one year later were identified. Documentation rates in the second and third periods did not differ from that prior to the intervention (1.3% vs. 0.0% and 0.0% in subsequent periods), nor did the rates of signature acquisition differ (85.3% vs. 85.3% and 78.6%). The accuracy of data entry was 92.6%. However, the frequency of call refusals decreased significantly after the intervention (from 9.0% to 2.0% and 6.6% in the respective periods). CONCLUSIONS: An educational intervention resulted in no change in the rate of decision-making capacity documentation or signature acquisition by ALS providers for refusal of transport. There was a temporary increase in the number of transported patients.

Consent Forms↗
PubMed2004

Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians.

OBJECTIVE: Computerized physician documentation (CPD) has been implemented throughout the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC. DESIGN: A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital. MEASUREMENTS: Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing. RESULTS: Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care. CONCLUSION: CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them.

Attitude of Health Personnel↗
PubMed2006

The medicolegal importance of enhancing timeliness of documentation when using an anesthesia information system and the response to automated feedback in an academic practice.

Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had < or = 2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained.

Academic Medical Centers↗
PubMedDate not supplied

Pharmacist care plans and documentation of follow-up before the Iowa Pharmaceutical Case Management program.

OBJECTIVES: To document drug therapy problems and their causes and assess pharmacist follow-up of patients with identified drug therapy problems. DESIGN: Cross-sectional analysis. SETTING: Iowa. PARTICIPANTS: 160 pharmacists who submitted 754 pharmaceutical care plans in an effort to qualify for participation in the Iowa Pharmaceutical Case Management program. INTERVENTIONS AND MAIN OUTCOME MEASURES: Care plans were assessed for drug therapy problems and causes and for documentation of pharmacist follow-up (actual, none, or intent to follow up). RESULTS: Pharmacists documented a wide variety of drug therapy problems and causes, including adverse drug reactions (20.1% of care plans), need for additional drug therapy (18.9%), lack of patient adherence to therapy (16.3%), incorrect medication being prescribed (14.1%), and drug dose too high (10.0%). Pharmacist follow-up with patients was not optimal, with 31% of care plans providing documentation of actual follow-up. Another 42.2% of plans indicated that the pharmacist intended to contact the patient for follow-up but either did not do so or did not record the intervention. No actual follow-up or intent to follow up was recorded in 26.8% of care plans. Pharmacists practicing in independent pharmacies followed up with patients more frequently than those in other settings (36.4% of care plans, compared with 22.7%, 23.2%, and 28.4% for chain, clinic, and franchise pharmacies). Pharmacists were more likely to follow up when the identified problem involved drug safety rather than effectiveness (36.2% versus 28.3% of care plans). CONCLUSION: Documentation of pharmacist follow-up with patients was less than optimal. In addition to identifying drug therapy problems and causes, pharmacists must complete the care continuum through documentation of patient monitoring and follow-up to transform the philosophy and vision of the pharmaceutical care concept into a practice of pharmacy recognized and rewarded by patients and payers.

Case Management↗
PubMed2002

Documentation of delirium in elderly patients with hip fracture.

This study determined the accuracy of diagnosis and documentation of delirium in the medical and nursing records of 55 elderly patients with hip fracture (mean age = 78.4, SD = 8.4). These records were reviewed retrospectively on a patient's discharge for diagnosis of delirium, and for description of clinical indicators or symptoms of delirium. Additionally, all patients were monitored by one of the research members on days 1, 3, 5, 8, and 12 postoperatively for signs of delirium, as measured by the Confusion Assessment Method (CAM). Clinicians were blinded to the purpose of the study. According to the CAM criteria, the incidence of delirium was 14.5% on postoperative Day 1; 9.1% on postoperative Day 3; 10.9% on postoperative Day 5; 7.7% on postoperative Day 8; and 5.6% on postoperative Day 12. For those same days, no formal diagnosis of delirium or a description of clinical indicators was found in the medical records. In the nursing records, a false-positive documentation of 8.5%, 4%, 4.1%, 4.2%, and 5.9%, respectively was noted. False-negative documentation was found in 87.5%, 80%, 66.7%, 75%, and 50% of the cases on the respective days. Documentation of essential symptoms--namely onset and course of the syndrome--and disturbances in consciousness, attention, and cognition, were seldom or never found in the nursing records. However, behaviors of the hyperactive variant of delirium and which are known to interfere with nursing care were documented more often (e.g., 13.4% restless, 10.3% fidget with materials, 7.2% annoying behavior). Both medical and nursing records showed poor documentation and under-diagnosis of delirium. However, a correct diagnosis and early recognition of delirium may enhance the management of this syndrome.

Age Factors↗
PubMed1993

Hospital mainframe computer documentation of pharmacist interventions.

The hospital mainframe computer pharmacist intervention documentation system described has successfully facilitated the recording, communication, analysis, and reporting of interventions at our hospital. It has proven to be time efficient, accessible, and user-friendly from the standpoint of both the pharmacist and administrator. The advantages of this system greatly outweigh manual documentation and justify the initial time investment in its design and development. In the future, it is hoped that the system can have even broader impact. Intervention/recommendations documented can be made accessible to medical and nursing staff, and as such further increase interdepartmental communication. As pharmacists embrace the pharmaceutical care mandate, documenting interventions in patient care will continue to grow in importance. Complete documentation is essential if pharmacists are to assume responsibility for patient outcomes. With time being an ever-increasing premium, and with economic and human resources dwindling, an efficient and effective means of recording and tracking pharmacist interventions will become imperative for survival in the fiscally challenged health care arena. Documentation of pharmacist intervention using a hospital mainframe computer at UIH has proven both efficient and effective.

Chicago↗
PubMed1997

UN/EDIFACT based medical documentation and messages.

New documentation and messages conforming to the rules of EDIFACT are created and an attempt is made to follow internationally standardised and wordwide available commercial experience. A set of medical documents, aligned with United Nations Layout Key for trade documents is designed. The approach is to develop a set of paper documents and to standardise the data which are filled in these documents. There is a possibility to fill the data directly in medical documents and to print them from the Clinical Information System in our University Hospital.

Bulgaria↗
PubMed1999

Electronic fetal monitoring. Are we meeting documentation standards?

OBJECTIVE: To test whether fetal heart rate documentation requirements for high-risk pregnancies are too stringent to achieve compliance, especially during the second stage of labor. STUDY DESIGN: Random retrospective chart and monitor strip review of deliveries occurring one year earlier were reviewed. Thirty-four low-risk and 34 high-risk pregnancies were selected and assessed for compliance with nationally accepted documentation guidelines. RESULTS: All monitor strips and charts were successfully retrieved from medical records. Charted documentation of the strips met national requirements in the active phase of the first stage of labor in 97% of cases, as did documentation during the second stage. For high-risk pregnancies, compliance during the active phase of the first stage of labor was 65% as compared to 35% in the second stage. All infants had normal five-minute Apgar scores, and none had umbilical arterial acidemia. CONCLUSION: Given current resources, we cannot reliably meet established documentation standards for high-risk pregnancies. Such overly stringent documentation standards pose a significant risk in cases going to litigation. A standard should be developed that is based on outcome data.

Adult↗
PubMed2001

Documenting patient refusals.

Patient morbidity and mortality, subsequent to either patient- or provider-initiated refusals, are noteworthy. It has been estimated that hospital admission is twice as likely after prehospital providers refuse a patient transportation to the hospital. In one particular study group, prehospital-provider refusal of transportation, as opposed to patient refusal of transportation, accounted for 73% of the post-refusal hospital admissions. Provider-initiated refusals are tantamount to a time bomb. There are very few justifiable provider-initiated refusals of treatment or transportation. If the call is of a non-emergency nature, the decision not to treat or transport should be a mutual agreement between the patient and provider. Consult with the online medical director for guidance as needed. Document the physician's name, consulting facility and medical direction. As with every patient encounter, a legally defensible runsheet should be completed. Should you write a report if your services are "not needed," or if you are canceled en route to the call? For your protection, a report archiving every run should be documented. If your services are canceled en route, note the canceling authority and time of cancellation. If your services are canceled at the scene, document the canceling authority, time of cancellation and the circumstance. It is important to specifically document that "no patient contacts were made." When patient contact is made, a patient-provider relationship is established, thereby redefining your duty to the patient. Protect yourself, your crew members, your chain of command, your jurisdiction and your agency by writing a legally defensible informed refusal report. According to one source, "Every negligence case in the last 30 years has been decided on its documentation." If it wasn't written down, it wasn't done. Be safe, and document safely.

Documentation↗
PubMed2001

Paragraph-oriented structure for narratives in medical documentation.

The authors present a 6 years experiment using a document- centered electronic patient record, based on a central document repository. The document management system is paragraph oriented and all documents are built automatically before editing using predefined ordered sets of para-graphs. Paragraphs can be preloaded with templates, text or images. Once edited, signed and printed, documents are again decomposed in paragraphs and permanently stored. This system, though the compositional aspect of paragraphs is limited and their semantic content wide, offers numerous advantages. The typology is easy to build and to maintain, it has been implemented widely in our hospitals without need for any natural language processing techniques and is used daily within commercially available text editors. The actual state of the system is discussed, emphasizing the structure of the documents, the various attributes and properties that have been needed in order to meet user's needs.

Documentation↗
PubMedDate not supplied

Web-based X-ray quality control documentation.

The department of radiology at the Medical College of Georgia Hospital and Clinics has developed an equipment quality control web site. Our goal is to provide immediate access to virtually all medical physics survey data. The web site is designed to assist equipment engineers, department management and technologists. By improving communications and access to equipment documentation, we believe productivity is enhanced. The creation of the quality control web site was accomplished in three distinct steps. First, survey data had to be placed in a computer format. The second step was to convert these various computer files to a format supported by commercial web browsers. Third, a comprehensive home page had to be designed to provide convenient access to the multitude of surveys done in the various x-ray rooms. Because we had spent years previously fine-tuning the computerization of the medical physics quality control program, most survey documentation was already in spreadsheet or database format. A major technical decision was the method of conversion of survey spreadsheet and database files into documentation appropriate for the web. After an unsatisfactory experience with a HyperText Markup Language (HTML) converter (packaged with spreadsheet and database software), we tried creating Portable Document Format (PDF) files using Adobe Acrobat software. This process preserves the original formatting of the document and takes no longer than conventional printing; therefore, it has been very successful. Although the PDF file generated by Adobe Acrobat is a proprietary format, it can be displayed through a conventional web browser using the freely distributed Adobe Acrobat Reader program that is available for virtually all platforms. Once a user installs the software, it is automatically invoked by the web browser whenever the user follows a link to a file with a PDF extension. Although no confidential patient information is available on the web site, our legal department recommended that we secure the site in order to keep out those wishing to make mischief. Our interim solution has not been to password protect the page, which we feared would hinder access for occasional legitimate users, but also not to provide links to it from other hospital and department pages. Utility and productivity were improved and time and money were saved by making radiological equipment quality control documentation instantly available on-line.

Computer Security↗
PubMed1992

Comparison of two systems for documenting pharmacist interventions in patient care.

Manual and computerized systems for documenting interventions by pharmacists at a large university teaching hospital are compared. The manual system allows patient data and pharmacist interventions to be quickly documented on written profiles. Completed forms are entered into a personal computer for analysis. The computerized system is a direct-entry version of the manual intervention log. Five screens allow pharmacists to enter information into a mainframe computer from any terminal. Data can be downloaded from the mainframe into a personal computer. During the first part of the study, nine pharmacists used the manual system for seven days. After a two-week pause, the same pharmacists used the computerized system for seven days. The systems were evaluated by using time-and-motion analysis and a questionnaire. Also, the number of interventions documented and the characteristics of each were compared. The mean +/- S.D. time required to document an intervention was significantly less with the computerized system (81.8 +/- 24.9 seconds) than with the manual system (100.7 +/- 37.3 seconds). Administrative time for analysis and report generation was also less with the computerized system. The pharmacists rated the computerized system more highly in terms of ease of use, accessibility, time efficiency, and acceptability. The number of interventions documented did not differ between the systems. A computerized system for documenting pharmacist interventions compared favorably with a manual system.

Chicago↗
PubMed2005

Nursing documentation in occupational health.

PURPOSE: Traditionally, nursing documentation has been consistent with hospital standards and legal definitions of clinical nursing practice. Identify data and information nurses need to be recorded in order to maintain the continuity and quality of nursing care and the efficiency of nursing performance is a research question that is moving professionals around the world. This study objective is to describe the analysis of nursing documentation in the patient records. METHODS: It is a retrospective study. The study was conducted in the ambulatory occupational health nursing; it was selected 111 patient records. Of these, in 106 we identified a total of 775 nursing records. The nursing records comprise the following dimension: identification, job history, health state, health and safety, psychological e socio- cultural, medical history, physical examination and nursing assessment. RESULTS: In the data set elements found as documented in the subjective data and objective data, there was higher frequency of data elements related to the following nursing dimensions: health state, health and safety, physical examination and nursing assessment. The dimension of job history we found that 25% of the nursing records did not documented information about the current work status of the patient. In addition, the current job activity 20.77% of the records), working day 9.03% of the records), job process 8.13% of the records), worksite exposure 8.0% of the records), environmental works 6.19% of the records), occupation 5.81% of the records), job time 4.39% of the records), before job activity 4.13 % of the records), and work location 3.23% of the records) were not also documented. CONCLUSION: In conclusion, the present study was an attempt to highlight the importance of data to be documented and organized in the existing information systems in the specific area of occupational health care. The adequate data collected can provide the right information to improve nursing care in this care setting and enhance health population.

Documentation↗
PubMedDate not supplied

Documentation of after-hours telephone contacts by family medicine residents.

It is not known how many of the telephone calls received by family medicine residents get documented in a retrievable form. This descriptive study attempted to answer this question by comparing a university telephone operator's logbook to the files of after-hours encounter slips kept in a university based family medicine training program. Over a period of 10 weeks, 38% of the calls recorded by the operator were documented by residents in a retrievable fashion. Second-year residents documented calls significantly more than third-year residents, and all residents kept better documentation on calls that concerned young children. Documentation varied significantly among individual residents but was not affected by the day or time of calls. These results suggest that having a system for recording after-hours telephone calls is not sufficient to ensure adequate documentation. Monitoring after-hours call records may provide a solution.

Adult↗
PubMedDate not supplied

[The Berlin Documentation System for Psychotherapy].

A Berlin Team for Documentation in Psychotherapy has developed an extensive documentation system. It provides data of a social, psychological and life-history nature, refering to computerized dataanalysis, which are pertinent in the psychological assessment of patients with neurotic and psychosomatic symptoms. The instrument which serves in collecting the data--a special type of psychoanalytic interview--has been used routinely in the Berlin-Group since 1951 to diagnose neurotic disturbances and to prognostically assess the chances for treatment. Interest in assessment-procedures which especially take into account the social situation of the patient, and the work on documentation procedures which treat psychological and social factors with equal weight, grew out of the tradition of the Psychoanalytic Ambulance of Berlin in the years between 1920 and 1940. The following report, in treating its historical development, describes the psychoanalytic interview as well as the psychoanalytic institutions whose large amount of experience in the treatment of patients made it possible to construct the documentation system (Institut für Psychogene Erkrankungen der AOK Berlin und Abteilung für Psychotherapie und Psychosomatische Medizin im Klinikum Charlottenburg). The authors present the specific elements of the datasystem: the patient's attitude towards his illness, his actual social environment, his early socialization process, personality structure and prognosis. They discuss the relationship between the documentation on the one hand and the process of psychoanalytic interview on the other, which necessitates both the understanding of the patient's life-history and his pattern of social interaction. The possibilities and limitations of the data evaluation especially in regard to ratings are discussed in its methodological aspects. The most important questions to be answered by this project are: Testing of psychoanalytic hypotheses with help of extensive data from numerous patients, the descriptive differentiation of neurotic personality patterns, the testing of social influences on psychosomatic disorders, and the construction of a short version of documentation with which comparative research on psychotherapy should be possible.

Berlin↗