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PubMedDate not supplied

[The Frankfurt child and adolescent psychiatry documentation system--development and methodological principles with reference to quality assurance].

Measures to ascertain qualified work in child and adolescent psychiatry have become a great necessity, because of increasing financial pressures and changing laws. One basic measure should be a documentation system, which should include reliable basic data on the patient, standardized data of the psychopathological status and the latest version of the Multiaxial Classification System (MAS). The second chapter gives a brief overview of the historic development of documentation systems in psychiatry resp. child and adolescent psychiatry. Only very recently a trend toward a generally binding standardization has emerged. The third chapter describes the general methodological principles of clinical documentation. Finally, the Frankfurt Child and Adolescent Psychiatry Documentation System is presented, which has been developed between 1987 and 1993 at the Department of Child and Adolescent Psychiatry of the Frankfurt University School of Medicine. It is presently used in several german university hospitals. It consists of a six-part documentation sheet, a detailed glossary and a special computer program for data entry and data administration. It includes sociodemographic and anamnestic data, the psychopathological and somatic status, diagnostic assessment for the MAS and data on therapeutic measures and treatment outcome. The computer program, which can be used on any IBM-compatible PC, allows easy data input on the screen, controls distribution of case numbers, plausibility of important core data and ongoing security copies. The possible use of the documentation system for clinical quality assessment is discussed.

Adolescent↗
PubMedDate not supplied

Time differences in handwritten and computer documentation of nursing assessment.

The increasing burden of documentation on nurses and the advent of improved computer technology prompted the development of a bedside documentation system. The time required for documentation of the nursing assessment and the number of observations recorded by the computer were compared with handwritten documentation. The time required for computer documentation using default charting of nursing assessment was significantly less than the time required for handwritten documentation. The number of observations recorded by computer was significantly greater than the number of observations recorded by hand.

Documentation↗
PubMed1996

[Automatic report documentation in cardiology using a speech recognition system].

Computer systems that can convert spoken text into written text have recently become available. In one such system, the phonetics of spoken words are compared with those of 32 000 stored words, with a statistical program helping to choose the word with the highest probability of being correct. We evaluated the practicability of the IBM Voice Type system for writing medical reports using a cardiologic vocabulary. A total of 200 medical documents were generated with a mean of 301 +/- 52 words. In the mean, 12 +/- 5 words were falsely recognized in each document, resulting in a rate of correct recognition of 95.1 +/- 2.5%. It is possible to correct a falsely recognized word by choosing an alternative word from a provided list, which worked in our case in 51% (6.1 +/- 2.8 words in each document). Correction of falsely recognized words had to be done by manual input 49% of the time (5.9 +/- 2.9 words in each document). The mean time demand for word correction amounted to 57 +/- 15 s for each document, whereas correction by manual input needed more time (37 +/- 14 s) than choosing from a list of alternative words (20 +/- 4s). A requirement for use of the Voice Type system is a reduced speech rate. Dictation of our documents took on average 260 s when done with a normal speech rate, and 400 s when done at a reduced speech rate. In conclusion, automatic writing of cardiologic reports can be done easily and with a low failure rate using the IBM Voice Type system with a cardiologic vocabulary. It takes about 3 min longer to create a medical text 1 1/2 pages long which is free of mistakes by using the Voice Type system than to simply dictate the text. Time can be saved by eliminating the need to check a preliminary report. The major advantage of automated reporting is that the written report is immediately available. For each discipline, specific vocabularies should be validated.

Cardiology↗
PubMed1996

[General automated documentation and performance data on the surgical intensive care unit--the theoretical concept of the Regensburg Surgical University Clinic].

Documentation is becoming an ever more time-consuming task due to the need to document increasing ICU productivity, quality management and cost-assessment data. Automatic charting of on-line monitoring data, therapeutic-device data, clinical laboratory data, microbiological data, radiological data and other data reduces documentation time significantly. One of the major advantages of PDMS in the SICU is the quality of the documentation and with better documentation the therapist is able to improve the quality of care. Not only the physician, but also nurses and physiotherapists are able to benefit from these advantages. Our concept, SURGIC (Department of Surgery, University Regensburg, Germany, Intensive Care), stands for: widely automated documentation, work orientation, including physicians, nurses' and physiotherapists' tasks, minimal dataset for simple use and perfect overview, costs assessments, scientific dataset, SICU PDMS as a part of the clinical information system, and professional support by a software-house is necessary.

Computer Systems↗
PubMed1997

Documenting resident procedure and diagnostic experience: simplifying the process.

BACKGROUND AND OBJECTIVES: The Residency Review Committee (RRC) requires documentation of family practice residents' procedural and diagnostic experiences. Further, hospital privileging is frequently based on documentation of prior clinical experience. Residency programs need a user-friendly (ie, resident-friendly) mechanism for collecting data and generating reports to document these experiences. This paper outlines a simplified, user-friendly method of documenting resident procedural and diagnostic experiences. METHODS: We developed a pocket-sized, optically scannable card for data input. This is coupled with a computerized database with report generation capability. The system is based on diagnostic clusters to further simplify the data input process. RESULTS: The system's setup costs are about $10,000. Annual maintenance and operational fees are about $5,000. After instituting the system, the number of residents submitting documentation information increased substantially. CONCLUSIONS: This system meets both RRC and potential clinical privileging requirements and provides a useful tool for guiding resident evaluation and developing appropriate training opportunities during the latter half of the residency. Simplified, accurate documentation may allow for comparisons among residents at various levels--program, state, and national.

Clinical Competence↗
PubMed1997

[The effect of specialist supervision on the quality of medical documentation in occupational health services].

The effect if different factors on the quality of documentation on medical prophylactic examinations in occupational health services is presented. Following the binding legal regulations, the tools (forms and application software) for evaluating the quality of documentation by regional specialists has been developed. The medical documentation has been kept by authorized doctors using old and new forms. The results of three successive controls carried out in three voivodships during the third term of 1996 showed improved quality parameters (transparency and input of appropriate data) due to new pattern of medical documentation. Nevertheless, the key role in quality assurance of medical documentation is played by a regional specialists, equipped with suitable tools facilitating assessment of documentation kept by individual doctors.

Documentation↗
PubMed1998

Topographic documentation of acute radiation morbidity.

BACKGROUND: The clinical knowledge on the frequency and severity of acute radiation morbidity is very sparse. With established morbidity recording, only severe side effects are revealed. The lower morbidity (I/II degree) as a major part of the data base is neglected. Another problem may be the lack of interdisciplinary and international compatibility in other systems. For these reasons, our intention was to create an easily acceptable, international and interdisciplinary compatible documentation form for routine use in radiotherapy. METHODS: A detailed topographic documentation sheet for each major topographic site of clinical radiation oncology has been developed (CNS, head and neck, thorax, female breast, abdomen, extremities). It is based upon existing toxicity codes and documentation systems (CTC[WHO], RTOG and EORTC, DEGRO, ADT, KIEL). Furthermore, basic oncological data like TNM, previous surgery or chemotherapy, drugs and more are included. For each topographic body site, one DIN A4 format is required for documentation of a 6 to 7-week treatment course. The toxicity prescription is coded according to the "DEGRO/RTOG Coding System for acute side effects" and to the "EORTC Acute Toxicity Code" to achieve optimal international and interdisciplinary compatibility. RESULTS: Complete documentation of toxicities level 0 to 4 is to be performed within 2 to 5 minutes per week/patient within preformed marks. The clinical performance has proven excellent. Not only level III/IV toxicities are recorded, but also level I/II morbidity. CONCLUSIONS: The topographic documentation system improves recording of acute morbidity in radiation oncology not only by time, but also in quality. Experimental, radiobiological and former clinical data may be proved for their actual plausibility.

Acute Disease↗
PubMed1989

Ranking documents with a thesaurus.

This article reports on exploratory experiments in evaluating and improving a thesaurus through studying its effect on retrieval. A formula called DISTANCE was developed to measure the conceptual distance between queries and documents encoded as sets of thesaurus terms. DISTANCE references MeSH (Medical Subject Headings) and assesses the degree of match between a MeSH-encoded query and document. The performance of DISTANCE on MeSH is compared to the performance of people in the assessment of conceptual distance between queries and documents, and is found to simulate with surprising accuracy the human performance. The power of the computer simulation stems both from the tendency of people to rely heavily on broader-than (BT) relations in making decisions about conceptual distance and from the thousands of accurate BT relations in MeSH. One source for discrepancy between the algorithms' measurement of closeness between query and document and people's measurement of closeness between query and document is occasional inconsistency in the BT relations. Our experiments with adding non-BT relations to MeSH showed how these non-BT non-BT relations to MeSH showed how these non-BT relations could improve document ranking, if DISTANCE were also appropriately revised to treat these relations differently from BT relations.

Abstracting and Indexing↗
PubMed2001

[Wide angle fundus documentation in retinopathy of prematurity].

BACKGROUND: Fundus documentation in preterm infants has been improved by the advent of a new wide-angle fundus camera (RetCam 120). PATIENTS AND METHODS: In 30 preterm infants we used the RetCam 120 for retinopathy of prematurity (ROP) screening, before and after laser treatment of ROP and after regression of acute phase ROP for documentation of fundus findings. The RetCam 120 is a digital contact wide-angle fundus camera which is based on a 3-chip CCD video camera. RESULTS: The RetCam 120 proved to be feasable for ROP documentation in preterm infants. Fundus documentation enhanced follow-up, teaching and cooperation between ophthalmologists and neonatologists. Conventional ophthalmoscopy is still necessary when using the RetCam 120 in ROP screening. Technical improvements of the camera itself and of the hardware and software is necessary before the RetCam 120 can be used routinely in ROP screening. CONCLUSION: The wide-angle fundus documentation using the RetCam 120 allows instant visualization and real-time documentation of intraocular findings. The RetCam 120 opens up new possibilities in clinical and scientific work, in teaching and in the new frontiers of ophthalmological telemedicine.

Fundus Oculi↗
PubMed1993

Symptoms and electrocardiographically documented rhythm preceding spontaneous shocks in patients with implantable cardioverter-defibrillator.

During a follow-up of 24 +/- 20 months after treatment with an implantable cardioverter-defibrillator (ICD), 101 of 241 patients (42%) received > or = 1 spontaneous ICD shocks with documentation of the rhythm leading to shock by Holter or telemetry monitoring or stored electrograms by the device. Sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) was documented in 67 of the 101 patients (66%) with electrocardiographically documented shocks, nonsustained VT in 4 patients (4%), supraventricular tachyarrhythmias in 41 patients (41%), and normal sinus or pacemaker rhythm in 10 patients (10%). No, mild (palpitations and/or mild dizziness) and severe symptoms (presyncope/syncope) preceded spontaneous ICD shocks in 20 (30%), 33 (49%) and 27 (42%) of the 67 patients, respectively, with electrocardiographically documented VT or VF, and in 23 (56%), 16 (39%) and 1 (2%) of the 41 patients, respectively, with electrocardiographically documented supraventricular tachyarrhythmias. Three of the 4 patients with nonsustained VT had mild symptoms, and 1 patient with nonsustained VT had presyncope. None of the 10 patients with spurious discharges during normal sinus or pacemaker rhythm had symptoms preceding the ICD shocks. It is concluded that (1) most patients with either electrocardiographically documented VT/VF or a non-VT/VF rhythm preceding spontaneous ICD shocks have no or mild symptoms preceding the shock, and (2) severe symptoms preceding ICD shocks suggest sustained VT or VF as the underlying rhythm, although severe symptoms rarely occur in patients with supraventricular tachyarrhythmias or nonsustained VT.

Adult↗
PubMed1997

An audit of trauma documentation.

Research into aspects of the care of the injured depends on accurate and complete documentation. Inadequate records make audit almost impossible and are unacceptable medico-legally. An audit was made of the standard of trauma documentation in the Yorkshire region before the introduction of trauma charts in 1992. After it was established that a problem did exist, an audit was made of the standard of documentation before and after introduction of trauma charts in one city teaching hospital. Case notes were inspected for completeness of documentation of respiratory, circulatory and neurological status. Results from 1988-1989 showed that only 39.4 per cent of notes recorded the four parameters under investigation. In 1992-1994 the standard had improved. Without trauma charts documentation increased to 90 per cent, but with trauma charts in primary referrals the result improved to 97 per cent. Only 56 per cent of notes were complete for tertiary referrals when a trauma chart was not used. The standard of documentation in major injuries improved with the use of trauma charts. It is recommended that trauma charts are used routinely for all primary and tertiary referrals of injured patients. Tertiary referral patients should be reassessed fully after hospital transfer and a new trauma chart completed.

Blood Pressure↗
PubMed1996

Documentation patterns before cataract surgery at ten academic centers.

PURPOSE: To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines. METHODS: In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation. Criteria for completeness were derived from the American Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsored guidelines. RESULTS: Twenty-six percent of charts lacked documentation of at least one of four basic elements of the preoperative evaluation. These four elements are (1) vision in the surgical eye; (2) vision in the fellow eye; (3) evaluation of the fundus, macula, or visual potential in the surgical eye: and (4) presence of some form (general or specific) of functional visual impairment. If, as stated in the guideline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria. CONCLUSION: Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of documentation and incompleteness of the examination is unknown. Improved documentation is needed to better measure and enhance the quality of care.

Academic Medical Centers↗
PubMed1996

Changing the relationship among nurses' knowledge, self-reported behavior, and documented behavior in pain management: does education make a difference?

An educational program designed to change knowledge in order to change pain management practices and patient outcomes was offered to nurses who provide day-to-day care to patients with cancer in communities in a predominantly rural state. A quasi-experimental time-series design was used to measure the effectiveness of the program in changing nurse knowledge, attitude and behavior, and to evaluate the relationships between the outcomes. Data were collected from nurses (N = 29) and patient charts before (N = 209) and after (N = 163) the program. Nurses' knowledge increased, but the change was not statistically significant; the mean percent of correct answers on the three subtests were different and differences persisted throughout the study. Nurses believed that patients should be "pain free." Documentation of behaviors, for example, practice activities, occurred infrequently and showed little change until 6 months after the program. Increase in documentation of pain-intensity ratings, pain location, number of sites of pain, presence of confusion, anxious or depressed mood, sleep, nausea and vomiting, constipation, and general activity were noted. Documentation of the use of a propoxyphene-containing analgesic decreased; increase in the use of hydromorphone methadone and transdermal fentanyl was noted. Analysis of the relationships between correct responses to nurse knowledge questions and documentation of behavior provided interesting, statistically insignificant results that need to be reexamined in future research. Future programs should emphasize analgesic dosing and calculation of equianalgesic doses. Current practices in chart documentation may provide incomplete information regarding change in practice behaviors; more detailed documentation of pain management practices is needed. Nurses who participated in the program anecdotally reported feelings of increased credibility and effectiveness. Although change in behavior is slow to occur, education does make a difference.

Adult↗
PubMedDate not supplied

Patient-initiated refusals of prehospital care: ambulance call report documentation, patient outcome, and on-line medical command.

INTRODUCTION: There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR. METHODS: The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up. RESULTS: Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p < 0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths. CONCLUSIONS: Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.

Adult↗
PubMed2001

Standards of documentation of the surgeon-patient consultation in current surgical practice.

BACKGROUND: This study was designed to assess the reliability of the system whereby junior doctors document the surgeon-patient consultation in general surgical practice in the UK. METHODS: A prospective observational study was carried out, with an independent observer recording details of the surgeon-patient consultation and assessing the reliability of documentation. An exact record of the information given by consultants was transcribed in shorthand at the time of consultation. Data were recorded in the categories recommended for notation by the General Medical Council: clinical findings, decisions made, information given to patient and treatment prescribed. Case notes were examined within 24 h of the ward round to ascertain reliability of the documentation. RESULTS: The study population comprised 432 surgeon-patient consultations. There were important deficiencies in the documentation of consultants' clinical findings and management decisions. In addition, information given by consultants to the patients regarding clinical findings and treatment planned (including the need for operation) was recorded in a median of 6 per cent of consultations. CONCLUSION: This study provides objective evidence of shortfalls in the documentation of the surgeon-patient consultation process. These deficiencies are such that, under present circumstances, the requirements of the General Medical Council with respect to case note documentation are not fulfilled in this setting.

Bias↗
PubMed1997

The Buckinghamshire nursing record audit tool: a unique approach to documentation.

A project to examine the quality of manual nursing documentation using an action research approach, prior to the introduction of a computerized system is described. The findings showed that there was a general lack of understanding about care planning. There was therefore a need to find an audit tool which could identify and develop nurses' knowledge of documentation as well as identifying the strengths and weaknesses of existing documentation. A literature review revealed Phaneuf's audit tool, but this proved difficult to use. Two nurse teachers agreed to develop their own documentation audit tool, based on the UKCC document on record keeping, which identifies criteria for effective documentation. A tool was developed which adopts a facilitative educational approach enabling the practitioner to audit and learn simultaneously. Much interest is being shown by other areas, and the questions are worded so that it could be used in a variety of settings.

Education, Nursing, Continuing↗
PubMed2003

Risk factor documentation in elective and emergency vascular surgical admissions.

OBJECTIVES: this study investigates current practice of risk factor documentation in a vascular unit and compares variations in risk factor assessment between elective and emergency admissions. METHODS: one hundred and forty-four patients who underwent vascular surgical intervention for atherosclerotic disease during the year 2000 were retrospectively identified from computerised database. Case note review collated demographic details, data on risk factor assessment and the nature of surgery. Data were analysed using SPSS statistical software. RESULTS: the male to female ratio was 2.3:1 with a median (range) age of 73 (31-95) years. For 55 (38%) emergency admissions the following risk factors were not documented; ischaemic heart disease (8), diabetes mellitus (10), hypertension (10), smoking habit (13) and antiplatelet therapy (18). For 89 (62%) elective admissions the following risk factors were not documented; ischaemic heart disease (11), diabetes mellitus (9), hypertension (4), smoking habit (5) and antiplatelet therapy (19). Sixty-six (72.5%) routine admissions and 11 (20.8%) emergency admissions had estimations of serum cholesterol documented (chi(2) p < 0.001). There were no statistically significant differences in the documentation of other risk factors between the 2 groups. CONCLUSION: risk factors are not documented consistently for emergency vascular surgical admissions. Staff education should aim to improve risk factor assessment for elective and emergency admissions to reduce cardiovascular events and possibly improve surgical outcome in patients with atherosclerotic disease.

Adult↗
PubMed1998

[Continuous improvement in anesthesiological quality documentation].

OBJECTIVE: The analysis of result variation in quality benchmarking projects in anaesthesia showed that ASA classification was often the most relevant parameter in distinction of risk groups. Thus the parallel description of the risk level of a patient both with the ASA classification and with particular risk parameters was examined critically. The hypothesis was tested that the documentation of both parameter groups in the running quality benchmarking projects does not lead to relevant information gain. As a pragmatic consequence we see the possibility to reduce the core dataset with significant reduction of the documentation workload. METHODS: With machine readable protocols or online computer documentation nearly all anaesthesias in hospitals in Hamburg were documented with the DGAI core data set and transferred to the project office of EQS Hamburg since 1992. We compared the predictory power of single and combined risk assessments for the incidence of particular AVBs (grade 3 to 5) in elective anaesthesias with that of ASA-classification. RESULTS: In 257,878 elective anaesthesias AVBs were documented in 14.5% of cases. Besides one exception no superior prediction power for AVB incidence could be demonstrated for any special risk assessment as compared with the ASA-classification. This is also true for the AVBs decompensated cardiac insufficiency, myocardial infarction, pulmonary embolism and cardiac arrest which are associated with high lethality. CONCLUSION: We assume that the documentation of risk factors in the core data set as predictors can be abandoned without major loss of information. This would be a first step towards reduction of the amount of data in quality assurance to get a core of especially meaningful parameters. It would lead to an increase in acceptance of the method and thus to an increase in the validity of its results.

Anesthesia↗