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At least 343 records · Page 19Linked to original sources
PubMedDate not supplied

National strategy document on HIV / AIDS launched.

The National HIV-AIDS Strategy document was launched on December 27, 1995, in simple rites in Malacanang with no less than President Fidel V. Ramos himself giving his famous thumbs-up sign as his way of endorsing the document for mass distribution and discussion. The 25-page strategy document was developed to "serve as a framework for both individual and community responses to the challenge of HIV infection and AIDS. It seeks to provide the appropriate context necessary for both independent as well as coordinated responses." The strategy presents nine major principles that need to be considered in developing and carrying out programs that aim to address the various dimensions of HIV infection and AIDS. These principles were presented, critiqued, and validated in several regional consultations held between June and September 1995, and participated in by representatives from government agencies and nongovernmental organizations. ISSA attended the launching ceremonies, having been an active member of the Committee on Policy Development of the Philippine National AIDS Council, which helped in the drafting and review of the document. Copies of the document are available at the STD/AIDS Unit of the Department of Health. It is encouraged that the document be discussed widely such that the strategy may be used to aid in the development and evaluation of programs on HIV/AIDS in the country.

Asia↗
PubMed2003

Documentation of violence risk information in psychiatric hospital patient charts: an empirical examination.

Studies have identified risk factors that show a strong association with violent behavior in psychiatric populations. Yet, little research has been conducted on the documentation of violence risk information in actual clinical practice, despite the relevance of such documentation to risk assessment liability and to conducting effective risk management. In this study, the documentation of cues of risk for violence were examined in psychiatric settings. Patient charts (n = 283) in four psychiatric settings were reviewed for documentation of violence risk information summarized in the MacArthur Violence Risk Assessment Study. The results revealed that particular patient and institutional variables influenced documentation practices. The presence of personality disorder, for example, predicted greater documentation of cues of violence risk, regardless of clinical setting. These findings have medicolegal implications for risk assessment liability and clinical implications for optimizing risk management in psychiatric practice.

Adult↗
PubMed2003

[The tobacco industry's internal documents and smoking prevention in Spain].

A 1998 agreement between several states in the USA and the tobacco industry made millions of pages of internal documents available to the public. Many of these documents contain information that the industry would have preferred to keep confidential. Systematic review of these internal documents constitutes a valuable resource for international tobacco control, since they are available on the Internet and can be accessed from anywhere in the world. These documents provide relevant and useful information to antismoking activists and researchers. To facilitate their use, the present article presents the electronic archives of the tobacco industry's documents, describes methods for conducting searches, and identifies the documents with information on the industry's tactics for manipulating Spanish politics and society for its own commercial interests during the 1970s, 1980s, and 1990s.

Humans↗
PubMed2004

The Clinical Document Architecture (CDA) enables electronic medical records to wireless mobile computing.

The Clinical Document Architecture (CDA) has proved to be a valuable and powerful standard for a structured exchange of clinical documents between heterogeneous software systems like a Hospital Information System and a Physician Office System. In this paper we want to show how the CDA can additionally be used in order to enhance the Hospital Information System's functionality: each patient related document contained in or generated from the HIS can be converted to a CDA/XML document. With the XML/XSLT-based transformation methods, those documents can be device-specifically transformed. We use this method to display HIS-content on mobile devices like Personal Digital Assistants (PDAs) by extracting the respective data fields from the HIS database, converting them to a CDA/XML document, which is transformed and sent to the mobile devices using a wireless intranet connection. Preliminary results and users' comments are promising, but further evaluation will be necessary. Our approach shows a generic model how clinical data can be dis-played on different devices independently from the underlying HIS using CDA.

Computer Communication Networks↗
PubMedDate not supplied

Assessment of a fax document for transfer of medication information to family physicians and community pharmacists caring for hemodialysis outpatients.

BACKGROUND: Studies have clearly identified the outpatient dialysis population as one that is at high risk for drug-related problems. The objective of this study was to evaluate whether a fax document was useful for community pharmacies and family physicians to notify these health care providers that their patient was receiving hemodialysis, to update medication and allergy records, provide dosing information on antibiotics and drugs to avoid, facilitate communication from the hemodialysis unit, and to decide if this was a worthwhile project to continue on an on-going basis. METHODS: Fax documents were sent to community pharmacists and family physicians of 70 hemodialysis patients from two different hemodialysis satellite units. The fax document consisted of a brief cover letter with contact numbers, a copy of the patient's medication and allergy list, a table of appropriate antibiotic doses and medications to avoid in dialysis, and a survey to evaluate this project's usefulness. Fisher's exact test was used to determine whether there were any significant differences between the family physician and community pharmacist responses. RESULTS: The survey response rate was 37%. Ninety-five per cent (20/21) of family physicians and 81% (22/27) of community pharmacists who responded to the survey would use the medication profile to update their records. Ninety-five per cent of family physicians and 93% of community pharmacies thought the fax document was an improvement in communication from the dialysis unit. Ninety per cent of family physicians and 85% of community pharmacies thought that the fax document was a worthwhile project for the dialysis unit to continue. No significant differences were found between family physician and community pharmacist responses. CONCLUSIONS: Implementation of a fax document for the transfer of medication information to family physicians and community pharmacists caring for hemodialysis patients aids in updating medication and allergy profiles, improves communication fom the dialysis unit and is considered a worthwhile project to continue on an ongoing basis.

Ambulatory Care↗
PubMed2006

Enhancing patient safety through electronic medical record documentation of vital signs.

As technology becomes more sophisticated in healthcare, there is increasing need to measure its impact on key quality indicators, such as error reduction, patient safety, and cost-benefit ratios. When a product is designed to decrease medical errors, the baseline error rate must be determined before implementation to accurately measure the impact. Given the opportunity to adopt a technology that would eliminate the need to manually document vital signs, a large Florida hospital decided to measure the current process and error rate of vital signs documentation. University Community Hospital in Tampa, Fla., designed a two-phase study to evaluate this process. Phase I of the study evaluated errors in the electronic medical record and traditional manual documentation. The results demonstrate that use of an EMR can reduce vital sign documentation errors by more than half compared with traditional manual documentation in paper charts. Researchers found the error rate for electronic vital signs documentation to be less than 5 percent, compared with the paper chart error rate of 10 percent.

Florida↗
PubMed2006

E-nursing documentation as a tool for quality assurance.

The article presents the results of a project with which we describe the reengineering of nursing documentation. Documentation in nursing is an efficient tool for ensuring quality health care and consequently quality patient treatment along the whole clinical path. We have taken into account the nursing process and patient treatment based on Henderson theoretical model of nursing that consists of 14 basic living activities. The model of new documentation enables tracing, transparency, selectivity, monitoring and analyses. All these factors lead to improvements of a health system as well as to improved safety of patients and members of nursing teams. Thus the documentation was developed for three health care segments: secondary and tertiary level, dispensaries and community health care. The new quality introduced to the documentation process by information and communication technology is presented by a database model and a software prototype for managing documentation.

Medical Records Systems, Computerized↗
PubMed1968

Development of methodologic tools for planning and managing library services. II. Measuring a library's capability for providing documents.

A method of measuring a library's capability for providing the documents its users need has been developed. The library is tested with a representative sample of such documents to determine how long would be required for users to obtain these documents. Test results are expressed in terms of a Capability Index, which has a maximal value of 100 only if all the sample documents are found "on shelf." Specific tests employing samples of 300 documents have been developed that are appropriate for academic and for "reservoir" biomedical libraries. Realistic field trials have demonstrated that these two tests are practical to administer and that test results are adequately reproducible. When strict comparability is not important, a library can test itself. In assessing a reservoir library, test results are supplemented by data on its typical processing time for interlibrary loan requests. Currently these tests are being used in a national survey. The general method is applicable to other types of libraries, provided appropriate test samples are established. If their limitations are clearly understood, these "Document Delivery Tests" can be valuable tools for planning and managing library services.

Information Services↗
PubMedDate not supplied

Hospital provider satisfaction with a new documentation system.

Nursing documentation is an important component of clinical nursing practice. It is estimated that 15%-20% of work time is spent documenting patient information and that documentation is the most common cause for overtime. An evaluation of hospital staff satisfaction with a recently implemented documentation system showed that 70% are satisfied with the new system; 75% agree that consistency of nursing documentation has improved; 72% agree that availability of records has improved; 78% agree the placement of the nursing documentation at the point of service facilitates location of data; and 65% agree there has been a decrease in the number of forms they have to review in order to locate nursing information.

Attitude of Health Personnel↗
PubMed1994

Establishing an integrated framework for documentation: use of a self-reporting health history and outpatient oncology record.

PURPOSE/OBJECTIVES: To describe the development and implementation of a succinct documentation system that provides all oncology team members with a quick and systematic approach to gathering information for care planning. DATA SOURCES: Published articles and books. DATA SYNTHESIS: The Nursing Documentation Committee at the Ottawa Regional Cancer Centre designed and implemented a self-reporting health history (SRHH) that provides baseline data for care planning and an outpatient oncology recore (OOR) that provides ongoing documentation of all patient assessment findings and subsequent care. The OOR combines flowsheet and progress note documentation on one form. These tools are used by all members of the oncology team. CONCLUSIONS: Through consistent use of the SRHH and OOR, quality of documentation has increased and nursing time spent on charting has decreased, thus enabling the oncology team to focus on direct patient care activities. Furthermore, enhanced communication among members of the oncology team has resulted in improved continuity of patient care. IMPLICATIONS FOR NURSING PRACTICE: The SRHH and OOR are time-efficient and cost-effective tools that can assist nurses in meeting legal, professional, and accreditation documentation standards.

Ambulatory Care↗
PubMed1993

Impact of a procedure-specific do not resuscitate order form on documentation of do not resuscitate orders.

BACKGROUND: Serious problems exist with respect to documentation of do not resuscitate (DNR) orders. We studied the impact of a procedure-specific DNR order form on documentation of these orders. METHODS: We prospectively compared DNR chart documentation during a 3-month period before and after implementation of a procedure-specific DNR order form. RESULTS: The order form was used in 41 (93%) of 43 charts after its implementation. Documentation of attending physician agreement with the DNR order form increased from 30 of 34 charts in which the order form was used). The number of orders where it was uncertain whether at least one component of acute cardiopulmonary life support-related procedures was to be performed decreased from 30 (88%) of 34 charts to three (7%) of 43 charts. The order form had no measurable impact on documentation of DNR discussion. Only 25% of the charts had any discussion of the risks and benefits of CPR. CONCLUSIONS: A procedure-specific DNR order form can improve documentation of DNR decisions. The reduction of uncertainty in these orders about the use of specific procedures can prevent errors in patient care.

Advance Directives↗
PubMed1996

Bedside glucose monitoring quality control practices. A College of American Pathologists Q-Probes study of program quality control documentation, program characteristics, and accuracy performance in 544 institutions.

OBJECTIVE: To investigate the adequacy of bedside glucose monitoring (BGM) quality control documentation and monitoring, characterize program structure and organization, and identify characteristics associated with the ability to produce accurate results. DESIGN AND SETTING: College of American Pathologists Q-Probes laboratory quality improvement study in 544 institutions. MAIN OUTCOME MEASURES: Percent compliance with quality control (QC) documentation, appropriate corrective action, and frequency of inappropriate patient testing, and the percentage of BGM results within +/-10% and +/-15% of a corresponding clinical laboratory glucose result. RESULTS: Five hundred forty-four institutions reviewed a total of 19543 individual QC paper documents from 2543 separate BGM instruments. Ninety percent of QC determinations that should have been performed and noted on these documents were recorded; of those performed, 2.8% of QC results were outside of the acceptable range. Thirty-two percent of the out-of-range QC results had no record of corrective action. There were 527 reported instances of one or more patients being tested when there was no record of corrective action for out-of-range QC results. There were 20665 undocumented potential QC events, with 2053 instances of one or more patients being tested when there was no documentation. Two hundred forty-two institutions submitted 6653 paired BGM and clinical laboratory results for comparison. Approximately 56% of BGM results were within +/-10%, and 74% were within +/-15% of the corresponding clinical laboratory result. Factors associated with better accuracy performance are discussed. CONCLUSIONS: There is a need for improving compliance with QC documentation, improving appropriate corrective action follow-through, decreasing the frequency of inappropriate patient testing, and improving BGM accuracy performance. We provide recommendations for improvement.

Blood Chemical Analysis↗
PubMed1993

[Computer-assisted surgery documentation in clinical routine practice].

In surgery, computer support is still of minor importance. It is the aim of this publication to outline the concept of a computer-assisted documentation system for surgical procedures, to describe the realization of the concept and to discuss the results of the evaluation. Planning of the system started in 1988 with an analysis of existing computer support at our clinic, definition of the parameters to be documented and determination of the classifications to be used, followed by a design for the system's use and a decision on hardware and software. The system is run on an IBM-compatible personal computer with three terminals, and the software used is MEDOS. The surgical procedures are documented with a four-level hierarchical classification related to the VESKA code and the internal university codes. After extensive training of the doctors, routine use commenced in 1991. Up to now 9837 operations have been documented by 35 surgeons. The system produces all necessary statistics and supports scientific studies and inquiries from individual doctors. A prospective evaluation of 300 consecutive operations demonstrated good compliance of the doctors and high data quality. To achieve optimal benefit from the use of computers it is recommended that departmental communication and documentation systems be gradually built up in surgical departments.

Attitude of Health Personnel↗
PubMedDate not supplied

Documentation of do-not-resuscitate orders in an Irish hospital.

BACKGROUND: Some studies have suggested that do-not-resuscitate (DNR) decisions are often documented poorly in European countries. AIM: To examine the use and documentation of DNR orders in a large Irish teaching hospital. METHODS: Resuscitation status of all inpatients on a single day was determined using interviews with nursing staff and examination of the nursing and medical case notes. RESULTS: Seventeen (3.5%) of 485 patients were identified as not for resuscitation. There was written confirmation of the DNR order in the nursing notes for 14 (82%) and in the medical notes for 15 (88%) patients; in two cases, it was reported that doctors were reluctant to write down the agreed decision. Documentation of DNR orders was by consultant (7), registrar (7) and intern (1). Discussion with patient (2), family (10) or both (1) was recorded in 14 cases. CONCLUSION: The majority of DNR orders were clearly documented by senior doctors and had been discussed with the patient or with the relatives. A number of problems were identified that might be avoided by development of guidelines regarding use and documentation of DNR orders.

Aged↗
PubMed2006

Documentation on the anesthetic record: Correlation with clinically important variables.

PURPOSE: A survey was undertaken at a single Academic Health Sciences Centre to document the opinions of anesthesiologists regarding what variables are important to document on the anesthetic record. A subsequent chart review of anesthetic records was undertaken to determine the extent to which these anesthesiologists record the variables they consider important. METHODS: A survey form was mailed to all practicing staff anesthesiologists at the four adult McGill University affiliated hospitals. Anesthesiologists were asked to rank 23 preoperative and 33 intraoperative variables on a scale from 1-5: (1 = essential; 2 = important; 3 = useful; 4 = not important; 5 = excessive information). All variables considered by consensus < or = 2 (important to essential) were then assessed as to whether they were recorded on 60 charts randomly selected from each of the four teaching hospitals. Only anesthetic records completed by staff anesthesiologists were evaluated. RESULTS: Ninety percent (47/52) of survey forms were completed and returned. Preoperative variables considered most important to document included examination of the patient's airway and allergy status. Intraoperative variables considered most important for documentation were the patient's vital signs. The only variable to have been recorded on all the anesthetic records was the anesthesiologist's name. The allergy status was the most recorded preoperative variable (84% of charts). The recording rates of intraoperative variables ranged from 100% (anesthesiologist's name, start time of anesthesia) to 24% (estimated blood loss). CONCLUSION: McGill anesthesiologists consider many preoperative and intraoperative variables to be important to document on the anesthetic record. However, subsequent chart review indicated that many of these variables are recorded inconsistently. The transmission of anesthesia-related medical information might be improved if anesthesiologists recorded more consistently information they consider to be important.

Adult↗
PubMed2005

Documented and clinically suspected bacterial infection precipitating intensive care unit admission in patients with hematological malignancies: impact on outcome.

OBJECTIVE: To assess the impact of documented and clinically suspected bacterial infection precipitating ICU admission on in-hospital mortality in patients with hematological malignancies. DESIGN AND SETTING: Prospective observational study in a 14-bed medical ICU at a tertiary university hospital. PATIENTS: A total of 172 consecutive patients with hematological malignancies admitted to the ICU for a life-threatening complication over a 4-year period were categorized into three main groups according to their admission diagnosis (documented bacterial infection, clinically suspected bacterial infection, nonbacterial complications) by an independent panel of three physicians blinded to the patient's outcome and C-reactive protein levels. RESULTS: In-hospital and 6-months mortality rates in documented bacterial infection (n=42), clinically suspected bacterial infection (n=40) vs. nonbacterial complications (n=90) were 50.0% and 42.5% vs. 65.6% (p=0.09 and 0.02) and 56.1% and 48.7% vs. 72.1% (p=0.11 and 0.02), respectively. Median baseline C-reactive protein levels in the first two groups were 23 mg/dl and 21.5 mg/dl vs. 10.7 mg/dl (p<0.001 and p=0.001) respectively. After adjustment for the severity of critical and underlying hematological illness and the duration of hospitalization before admission documented (OR 0.20; 95% CI 0.06-0.62, p=0.006) and clinically suspected bacterial infection (OR 0.18; 95% CI 0.06-0.53, p=0.002) were associated with a more favorable outcome than nonbacterial complications. CONCLUSIONS: Severely ill patients with hematological malignancies admitted to the ICU because of documented or clinically suspected bacterial infection have a better outcome than those admitted with nonbacterial complications. These patients should receive advanced life-supporting therapy for an appropriate period of time.

Adult↗
PubMed2002

A new method for digital video documentation in surgical procedures and minimally invasive surgery.

BACKGROUND: Documentation of surgical procedures is limited to the accuracy of description, which depends on the vocabulary and the descriptive prowess of the surgeon. Even analog video recording could not solve the problem of documentation satisfactorily due to the abundance of recorded material. By capturing the video digitally, most problems are solved in the circumstances described in this article. METHODS: We developed a cheap and useful digital video capturing system that consists of conventional computer components. Video images and clips can be captured intraoperatively and are immediately available. The system is a commercial personal computer specially configured for digital video capturing and is connected by wire to the video tower. Filming was done with a conventional endoscopic video camera. A total of 65 open and endoscopic procedures were documented in an orthopedic and a thoracic surgery unit. The median number of clips per surgical procedure was 6 (range, 1-17), and the median storage volume was 49 MB (range, 3-360 MB) in compressed form. The median duration of a video clip was 4 min 25 s (range, 45 s to 21 min). Median time for editing a video clip was 12 min for an advanced user (including cutting, title for the movie, and compression). The quality of the clips renders them suitable for presentations. CONCLUSION: This digital video documentation system allows easy capturing of intraoperative video sequences in high quality. All possibilities of documentation can be performed. With the use of an endoscopic video camera, no compromises with respect to sterility and surgical elbowroom are necessary. The cost is much lower than commercially available systems, and setting changes can be performed easily without trained specialists.

Documentation↗
PubMed2002

[CleftData. Program for minimal documentation of lip-jaw-palate clefts].

BACKGROUND: The aim of the German Study Group on Cleft Lip and Palate-Craniofacial Deformities is to develop a precise system for documentation of cleft lip and palate patients which is suitable for use in PC-databases. DOCUMENTATION: In cooperation with the medical disciplines involved in the therapy such as otolaryngology, oral and maxillofacial surgery, orthodontics and speech therapy a system of documentation was developed with regard to the international classification of diseases (ICD) and the operating procedures system (OPS). Malformations are classified with the LAHS coding system. In addition to this concept of minimal documentation photographic images in standardized projections are stored. Furthermore, each operative procedure is documented by its date and the anatomic region of malformation treated without details of operative methods or descriptions of other procedures. SOFTWARE: On behalf of the German Study Group on Cleft Lip and Palate a software to meet these purposes was developed called CleftData. Based on a relational Access database it is equipped with SQL connectivity enabling its use on all hard- and software-systems.

Cleft Lip↗