Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Records”

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

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

At least 37 records · Page 2Linked to original sources
PubMedDate not supplied

Shuval automated problem-oriented record: an off-line record for a primary care clinic.

An off-line system for automating the problem-oriented record implemented at Kibbutz Shuval is described. The Shuval problem-oriented record consists of acute and chronic problem lists, a preprinted data base collected by patients and nurses, problem-oriented plan flow sheets, problem-oriented progress notes and a regular record audit. The mean conversion time from a traditional record to a problem-oriented record was 17 min for a child's record and 25 min for an adult's. The automated problem-oriented record consists of three data processing forms that contain almost all data in the record. Transfer of data took, on the average, 10 min (range, 5 to 30 min) for a child's record. The following five types of analysis can be performed with the Shuval automated problem-oriented record: administrative, patient care, epidemiologic, demographic and clinical research. Coupled with the manual problem-oriented record, the Shuval automated record provides many advantages of an on-line problem-oriented record at considerably less cost.

Computers↗
PubMed2001

Lateralizing and localizing values of ictal onset recorded on the scalp: evidence from simultaneous recordings with intracranial foramen ovale electrodes.

PURPOSE: The value of scalp recordings to localize and lateralize seizure onset in temporal lobe epilepsy has been assessed by comparing simultaneous scalp and intracranial foramen ovale (FO) recordings during presurgical assessment. The sensitivity of scalp recordings for detecting mesial temporal ictal onset has been compared with a "gold standard" provided by simultaneous deep intracranial FO recordings from the mesial aspect of the temporal lobe. As FO electrodes are introduced via anatomic holes, they provide a unique opportunity to record simultaneously from scalp and mesial temporal structures without disrupting the conducting properties of the brain coverings by burr holes and wounds, which can otherwise make simultaneous scalp and intracranial recordings unrepresentative of the habitual EEG. METHODS: Simultaneous FO and scalp recordings from 314 seizures have been studied in 110 patients under telemetric presurgical assessment for temporal lobe epilepsy. Seizure onset was identified on scalp records while blind to recordings from FO electrodes and vice versa. RESULTS: Bilateral onset (symmetric or asymmetric) was more commonly found in scalp than in FO recordings. The contrary was true for unilateral seizure onset. In seizures with bilateral asymmetric onset on the scalp, the topography of largest-amplitude scalp changes at onset does not have localizing or lateralizing value. However, 75-76% of seizures showing unilateral scalp onset with largest amplitude at T1/T2 or T3/T4 had mesial temporal onset. This proportion dropped to 42% among all seizures with a unilateral scalp onset at other locations. Of those seizures with unilateral onset on the scalp at T1/T2, 65.2% showed an ipsilateral mesial temporal onset, and 10.9% had scalp onset incorrectly lateralized with respect to the mesial temporal onset seen on FO recordings. In seizures with a unilateral onset on the scalp at electrodes other than T1/T2, the proportions of seizures with correctly and incorrectly lateralized mesial temporal onset were 37.5 and 4.2%, respectively. Thus the ratio between incorrectly and correctly lateralized mesial temporal onsets is largely similar for seizures with unilateral scalp onset at T1/T2 (16.7%) and for seizures with unilateral scalp onset at electrodes other than T1/T2 (11.2%). The onset of scalp changes before the onset of clinical manifestations is not associated with a lower proportion of seizures with bilateral onset on the scalp, or with a higher percentage of mesial temporal seizures or of mesial temporal seizures starting ipsilateral to the side of scalp onset. In contrast, the majority (78.4%) of mesial temporal seizures showed clinical manifestations starting after ictal onset on FO recordings. CONCLUSIONS: A bilateral scalp onset (symmetric or asymmetric) is compatible with a mesial temporal onset, and should not deter further surgical assessment. Although a unilateral scalp onset at T1/T2 or T3/T4 is associated with a higher probability of mesial temporal onset, a unilateral onset at other scalp electrodes does not exclude mesial temporal onset. A unilateral scalp onset at electrodes other than T1/T2 is less likely to be associated with mesial temporal onset, but its lateralizing value is similar to that of unilateral scalp onset at T1/T2. The presence of clinical manifestations preceding scalp onset does not reduce the localizing or lateralizing values of scalp recordings.

Adolescent↗
PubMed1994

[Recording characteristics of the eye mark recorder in measurements of vertical eye movements].

Electronystagmography (ENG) has been widely used in physiological studies of eye movements. It is generally known that ENG is at a disadvantage in recording the vertical component of eye movements, and thus there has been a great deal of difficulty in physiological studies of vertical eye movements using ENG. The eye mark recorder is an instrument which has already been used in the study of visual point movement in various situations. We tried to apply the eye mark recorder to the recording of eye movements in normal volunteers, and then compared its recording characteristics with those of ENG. When recording vertical eye movements with the eye mark recorder there is little baseline drift and no confusing waves caused by blinking, which is sometimes misinterpreted as nystagmus. The result is easy calibration of the device and more accurate measurement of the slow-phase velocity of nystagmus than ENG. Recording with the eye mark recorder is atraumatic and allows binocular visual stimulation. There are certain other techniques, such as search coil or video oculography, which allow more accurate recording of vertical eye movements than ENG. The search coil techniques, however, requires the attachment of a measuring contact lens during the examination and video oculography is still in development process, so both of them are difficult to use widely. Thus, we found that the eye mark recorder has a great advantage in recording the slow-phase eye velocity of vertical nystagmus and the vertical component of smooth eye movements in humans. We think that eye mark recorder can serve as a powerful new tool to investigate vertical OKN and OKAN.

Adult↗
PubMedDate not supplied

Computerized patient anesthesia records: less time and better quality than manually produced anesthesia records.

STUDY OBJECTIVE: To compare manual and computerized anesthesia information management systems (AIMS's) with respect to time demands on the anesthetist and record quality. DESIGN: Videotaped clinical anesthesia cases were independently reviewed along with the records produced. SETTING: Private practice anesthesia at a 150-bed community hospital. PATIENTS: Ten consecutive ASA physical status I patients having video arthroscopy of the knee by the same surgeon and having general anesthesia. INTERVENTIONS: One anesthetist recorded six cases: three with the computer and three manually. Two more anesthetists each recorded two cases: one with the computer and one manually. MEASUREMENTS AND MAIN RESULTS: The proportion of the anesthetist's time spent on the documentation for the computer records was significantly less than that spent on manual records (14.9% vs. 36.6%; p < 0.001). Nevertheless, significantly more vital sign data points were recorded on the computer than on the manual records (245.2 vs. 45.0 vital sign points per case; p < 0.001), as well as significantly more notes and drug information (61.0 vs. 40.0 notes per case; p < 0.02). The computer record was always legible, but this was not the case with the manual records. There was no significant difference in the number of artifacts detected on the records. CONCLUSION: The concern that the introduction of computerized AIMS's may complicate the anesthesia working environment by requiring more time than manual AIMS's and thus detracting from direct patient care is not supported by this study. In fact, this computer approach not only required less time but also produced a more complete and higher-quality record than did the manual AIMS.

Anesthesiology↗
PubMed2001

The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions.

The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions. Data from patient records will increasingly be used for care planning, quality assessment, research, health planning and allocation of resources. Knowledge about the accuracy of such secondary data, however, is limited and only a few studies have been conducted on the accuracy of nursing recording. The aim of this study was to analyse the concordance between the nursing documentation in nursing homes and descriptions of some specific problems of nurses and patients. Comparisons were made between wards where nurses had received training in structured recording based on the nursing process (study group) and wards where no intervention had taken place (reference group). Data were collected from the patient records of randomly selected nursing home residents (n=85). The methods used were audits of patient records and structured interviews with residents and nurses. The study revealed considerable deficiencies in the accuracy of the patient records when the records were compared with the reports from nurses and residents. The overall agreement between the interview data from nurses and from the patient records was low. Concordance was better in the study group as compared with the reference group in which the recorded data were structured only following chronological order. The study unequivocally demonstrates that there are major limitations in using records as a data source for the evaluation, planning and development of care.

Aged↗
PubMed2006

Characteristics of unmatched maternal and baby records in linked birth records and hospital discharge data.

Linkage of routinely collected health data collections is increasingly being used to investigate maternal and infant morbidity and mortality. Such data have the advantage of being population based and readily available. However, in using such data it is important to understand the data linkage process, the proportions of unmatched records and the characteristics of these records so that potential bias can be recognised. This article describes the differences in characteristics of matched and unmatched mothers' and babies' records generated in the linkage of birth records with hospital discharge data and explores some of the reasons for these differences. The study population included over 250,000 women and their babies discharged from hospital following delivery in New South Wales, Australia between 1 January 2000 and 31 December 2002. Hospital discharge and birth data were linked using probabilistic linkage methods for both mothers and babies. Matching rates were 98.5% and 99.0% for maternal birth and hospital discharge records, respectively, and 98.8% and 99.4% for baby records. Unmatched maternal records had higher proportions of Australian-born women, private hospital births and stillbirths compared with matched records. Unmatched baby records had higher proportions of low-birthweight babies, preterm births and in-hospital deaths than matched records. With the possible exception of stillbirths, these differences are unlikely to cause important bias in studies relying on matched records only. Our results suggest studies using linked data should generally examine and report on the characteristics of unmatched records, and recognise them as a potential source of bias.

Bias↗
PubMed1997

Fat-gram counting and food-record rating are equally effective for evaluating food records in reduced-fat diets.

OBJECTIVE: To compare rates of adherence to low-fat diets using food-record rating and fat-gram counting, to evaluate dietary adherence using the fat-gram counting method, and to assess correlations between food-record rating and fat-gram counting. DESIGN: A diet monitoring and observation study was conducted to compare the effectiveness of food-record rating and fat-gram counting to evaluate dietary adherence. Subjects were randomly assigned to the food-record rating group of the fat-gram counting group. Each participant was asked to complete four 3-day food records. Food records were evaluated by food-record rating for one group and by fat-gram counting for the other. Each record was then scored using the alternate system. For a subset, manually calculated fat-gram values were compared for accuracy with values from the Nutrient Data Systems database. STATISTICAL ANALYSES PERFORMED: Mantel-Haenszel chi 2, regression, and K analyses were used to evaluate adherence rates and within-subject agreement between fat-gram counting and food-record rating. SUBJECTS/SETTING: Seventy-eight participants were recruited from a lipid-lowering research trial conducted in Houston, Tex. RESULTS: Strong correlations were found between fat-gram values calculated manually and those calculated using the Nutrient Data Systems. No significant differences in adherence rates were found between the food-record rating and fat-gram counting groups. CONCLUSIONS: Fat-gram counting is at least as effective as food-record rating in monitoring dietary fat content. Dietitians can use it as an alternative dietary fat-monitoring procedure for clinical practice and research.

Diet Records↗
PubMed2001

What does the medical record reveal about functional status? A comparison of medical record and interview data.

OBJECTIVE: Functional status measures are potent independent predictors of hospital outcomes and mortality. The study objective was to compare medical record with interview data for functional status. SUBJECTS AND METHODS: Subjects were 525 medical patients, aged 70 years or older, hospitalized at an academic medical center. Patient interviews determined status for 7 basic activities of daily living (BADLs) and 7 instrumental activities of daily living (IADLs). Medical records were reviewed to assess documentation of BADLs and IADLs. RESULTS: Most medical records contained no documentation of individual BADLs and IADLs (61% to 98% of records lacking documentation), with the exception of walking (24% of medical records lacking documentation). Impairment prevalence was lower in medical records than at interview for all BADLs and IADLs, and agreement between interview and medical record was poor (kappa < 0.40 for individual BADLs and IADLs). Sensitivity of the medical record for BADL and IADL impairment was poor (range 95% to 44%), using the interview as a reference standard. Sensitivity and specificity of the medical record for detection of BADL and IADL impairment changed substantially when records with nondocumentation of functional status were excluded or were assumed to be equivalent to independence. CONCLUSIONS: The results suggest that the medical record is a poor source of data on many functional status measures, and that assuming that nondocumentation of functional status is equivalent to independence may be unwarranted. Given the prognostic importance of functional status measures, the results highlight the importance of developing reliable and efficient means of obtaining functional status information on hospitalized older patients.

Academic Medical Centers↗
PubMed1998

Establishment of a 24-hour electrocardiogram recording system using a Holter recorder for miniature swine.

A Holter recording system was established for the Göttingen miniature swine. For this purpose, we first developed a jacket to hold a Holter recording set, and subsequently determined a bipolar lead suitable for obtaining stable electrocardiogram (ECG) recording without artifacts. To make the jacket, we measured the lengths of eight sites of the body of 14 miniature swine. Several types of jackets were made and tested. We observed the behaviour of animals with these jackets by videotape recorder (VTR) recording. These observations permitted development of a jacket suitable for Holter recording. The jacket permits easy placement of the recorder, and long-term ECG recording can be performed without difficulty. In order to determine a suitable lead for long-term recording, we recorded ECGs from six adult miniature swine using three types of leads, the M-X, R-L and A-B leads. The R-L lead frequently exhibited baseline drift, and QRS complexes often disappeared in this lead due to low amplitude. ECG recording with the M-X and A-B leads was of sufficient quality to permit analysis. This system is expected to be useful for further cardiovascular research in miniature swine.

Anesthesia↗
PubMed2004

Retrieving physiotherapy patient records in selected health care facilities in South Africa--is record keeping compromised?

PURPOSE: The purpose of this study was to evaluate the process and feasibility of retrieving patient records in a variety of physiotherapy care settings in the Gauteng province in the Republic of South Africa. METHODS: Thirteen public and private health care facilities providing physiotherapy services were studied. Multiple methods of data collection (facility walk-through observation aided by a researcher designed checklist, in-depth interviews and attempting to retrieve physiotherapy records) were employed to evaluate the process of retrieving physiotherapy patient records, determine physiotherapy record retrieval rates and to determine the factors that were influencing record retrieval. RESULTS: The process of retrieving physiotherapy records was arduous and multi-faceted, with some health care facilities allowing patients to take their records home. A final retrieval rate of 46% (36.3% - 100%) was obtained. An odds ratio calculation revealed that it was 13.09 (CI: 8.99 - 19.13; p<0.001) times more possible to retrieve records of patients treated in private physiotherapy care settings (87.4% retrieval rate) than in public sector physiotherapy care settings (34.67% retrieval rate). CONCLUSIONS: This study concludes that the process of retrieving physiotherapy records was arduous and lacked uniformity in public sector hospitals. Further a low physiotherapy record retrieval rate was obtained.

Community Health Services↗
PubMed2004

Which data source in clinical performance assessment? A pilot study comparing self-recording with patient records and observation.

OBJECTIVE: A pilot study aimed to determine the extent to which each of three data sources could provide complete and reliable data for valid assessment of clinical performance. DESIGN: Clinical decisions taken in 168 consultations by seven family physicians were reviewed against guidelines for 15 clinical conditions. In total, 206 criteria were reviewed using three sources: medical records, observation in surgery, and structured self-recording by the physicians. SETTING AND PARTICIPANTS: Seven family practices in the Netherlands. MAIN MEASURE: Scores (%) of data recorded/total were obtained for each method. Kappa scores for the agreement between the three data sources were also obtained. RESULTS: Medical record examination provided 40%, observation 72%, and physician self-recording 95% of the data required for the review against guidelines. Nine per cent of the clinical decisions could be reviewed when using medical records, 46% when using observation data, and 69% when using data from prospective self-recording. In particular, decisions in the area of patient education and diagnostic examinations could not be reviewed validly using medical records only. Kappa agreements between the data available from the three sources as well as between the review results appeared to be 0.79. CONCLUSIONS: Medical records alone only supply sufficient information for the review of a very limited set of clinical decisions. Physician self-recording has significantly more potential for valid review of a broad range of clinical decisions. Furthermore, self-recording seems a reliable data collection method that deserves further research.

Clinical Competence↗
PubMedDate not supplied

Releasing pre-adoption birth records: the impact of Oregon's experience on its vital records department.

OBJECTIVE: In November 1998, Oregon voters passed Ballot Measure 58, which allowed Oregon adoptees > or = 21 years of age access to their original birth records, which are sealed at adoption. The objective of this study was to evaluate the impact of the measure on the Oregon Health Division (since renamed Oregon Health Services) by assessing procedures used and resources needed after implementation of Measure 58. METHODS: Vital records employees were interviewed about processing, storage, and archive retrieval procedures for pre-adoption birth records before, during, and after the implementation of Measure 58 and the effect on their usual workload. Personnel time, space, and fiscal resources used to process requests for pre-adoption records were also calculated. RESULTS: The Oregon Health Division began to receive requests from adoptees immediately following the passage of Measure 58 in November 1998, but due to legal challenges, they could not be processed until May 31, 2000. From June 2, 2000, through October 20, 2000, 12 staff members and two supervisors issued more than 4,700 pre-adoption birth records while also processing their normal workload, which averages more than 135,400 vital record orders annually. Due to the need for retrieval from archives, requests for pre-adoption birth records were estimated to take 75 hours to process vs. 2-3 minutes for standard requests. Each batch of approximately 75 pre-adoption birth records required approximately 12.5 person-hours from vital records staff and 3-4 person-hours from archive personnel; in addition, supervisors spent time responding to incomplete orders, informing the public and the media, and responding to concerns of adoptees, birth parents, and adoptive parents. Fewer than 1% of requests went unfilled. CONCLUSIONS: Implementation of Measure 58 utilized substantial resources of the Oregon Health Division. States contemplating similar legislation should consider increasing personnel and resources, preparing for intense public and media interest, and reorganizing the storage of adoptees' original birth records so they are easily retrieved.

Access to Information↗
PubMed1998

Consistency of unitary shapes in dual lead recordings from myelinated fibres in human peripheral nerves: evidence for extracellular single-unit recordings in microneurography.

Percutaneous microneurography is a powerful technique allowing studies of activity in single nerve fibres of conscious humans. However, the mechanisms by which single-unit recordings are achieved with this technique are not fully understood. To further elucidate these mechanisms, dual-lead recordings, using a modified concentric needle electrode with two separate recording surfaces at the tip, were performed in normal subjects. Sixty-two single units supplied by large myelinated afferents were studied. The majority (90%) of the units were recorded simultaneously on both surfaces but with different action potential amplitudes. Four types of unitary waveforms were encountered. The potentials recorded on the two channels were of the same type, although occasionally some details differed. Parallel waveform changes of the same units occurred simultaneously on the two surfaces. A displacement of a single fibre from one recording surface to the other with or without concomitant waveform-type transitions was observed when the electrode was slightly repositioned intraneurally. The results provided direct evidence to confirm that concentric needle electrodes record single-unit activity extracellularly from myelinated nerve fibres, probably at or close to a node of Ranvier. All the types of action potentials encountered with conventional tungsten electrodes were also identified in dual-channel recordings with concentric electrodes, which casts doubt on the previous explanation that single-unit activity recorded with tungsten electrodes is derived from intracellular sources. Some biological and technical aspects of the findings are discussed, especially concerning the applicability of in vivo measurements of the time course of the action potentials in humans and ways to improve microneurography towards multichannel recordings.

Action Potentials↗
PubMed1986

Methods to assess relative reliability of diet records: minimum records for monitoring lipid and caloric intake.

A total of 252 diet records of 18 outpatients attending a lipid clinic were analyzed by a computer-assisted method to determine the minimum number of daily diet records that would be reliable for monitoring dietary adherence. Each subject recorded food intake in special diaries for 14 consecutive days between two clinic visits. All possible randomly selected combinations of 3, 4, 5, 7, 9, and 11 consecutive days of records in the 14-day period were analyzed for calories and lipids. Sets of records were said to be within a 95% confidence interval when the information yielded on any parameter differed by 5% or less from the mean values for the entire 14 days' records. All sets of records for 7, 9, and 11 days were in the 95% confidence range; therefore, 7 consecutive days of food recording were considered the minimum requirement for a 95% confidence limit. Out of 11 possible combinations of 4 consecutive day-sets of records, all but 3 sets were within 95% confidence limits. Consequently, 4 consecutive days of records were deemed acceptable as a reasonable compromise for minimal, reliable monitoring of diet compliance in outpatients for the nutrients studied.

Adult↗
PubMed1985

Recording electrophysiological data on video tape: a superior and less costly alternative to conventional tape recorders.

Electrical potentials recorded extracellularly from the sinus gland of the isopod, Oniscus asellus, were stored on video tape with the aid of a digital-audio (DA) processor and a video cassette recorder (VCR). The DA processor transforms the analog signal to digital pulses of equal amplitude and converts these pulses into a television signal for recording on video tape. In playback, the DA processor reconverts the pulses to an analog signal with negligible distortion. When viewed on the oscilloscope screen, electrical potentials reproduced by this method were indistinguishable from electrical potentials recorded 'live' from the sinus gland. However, electrical potentials recorded from the same sinus gland and reproduced by a conventional FM tape recorder were easily differentiated from the 'live' recording. The special effects inherent in the VCR (e.g. stop action, frame advance) also permitted detailed analysis of spontaneously occurring electrical potentials. Special effects were not possible with the FM tape recorder. The price, ease of operation and ability to produce extremely high quality recordings, makes the DA processor and VCR an exceptional system for storing electrophysiological data.

Animals↗