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At least 379 records · Page 21Linked to original sources
PubMed2004

More 'cries from the joints': assessment of the musculoskeletal system is poorly documented in routine paediatric clerking.

OBJECTIVES: The aim of this study was to describe the assessment of the musculoskeletal (MSK) system in comparison with other systems in routine paediatric medical clerking. Furthermore, to survey trainee paediatricians (SPRs, specialist registrars) about their self-rated confidence in assessing the MSK system. METHODS: Case notes of consecutive general paediatric medical patients admitted to three UK hospitals over a 4-week period were assessed using a standard pro forma. All patients had been assessed by a consultant paediatrician during their admission. A postal questionnaire was sent to all SPRs in training in each of the hospitals, regarding their confidence in assessing the MSK system compared with other systems and their exposure to MSK teaching. RESULTS: Case notes of 257 patients [117 females, median age 3 yr (range 1-18 yr)] were reviewed. The most common reason for admission was acute infection, although the spectrum of other recorded diagnoses varied between hospitals. Thirteen children (5%) had an acute problem (e.g. infection) against a background of chronic disease. The case note documentation showed that cardiovascular (CVS), respiratory (RS) and gastrointestinal (GI) systems were assessed in the vast majority (>90%) of patients, irrespective of the underlying diagnosis. However, other systems were less well recorded; the trend being the same in each hospital and in descending order, the neurological system (38%), skin (32%), eyes (10%) and musculoskeletal system (4%). Only 2.7% (7/257) patients were documented to have been asked about MSK symptoms, and only 1.6% (4/257) had any documentation of joint examination--in all cases this was limited (e.g. range of movement of the knee only), and no patients had documentation of gait being examined, even in those children presenting with 'limp'. The response rate to the postal questionnaire was 60% (67/112). The self-rated confidence in MSK assessment was markedly low in comparison with other systems, even though 61/67 recalled some teaching of the MSK system as an undergraduate (61/67) or postgraduate (50/67). Of note none could recall teaching as an undergraduate in paediatric MSK assessment and where there had been postgraduate rheumatology MSK teaching this had been delivered by paediatric rheumatologists in many cases (34/50), reflecting the centres participating in the study. CONCLUSIONS: In routine general paediatric medical in-patient clerking and throughout the admission, MSK assessment was rarely documented, and even where present was limited. This contrasts markedly with other systems which were examined in most children irrespective of the presenting complaint. Self-rated confidence in MSK assessment is low amongst SPRs compared with other systems, despite most recalling some teaching. This discrepancy between teaching and clinical practice needs to be addressed in undergraduate and postgraduate training.

Adolescent↗
PubMed2007

Automated documentation error detection and notification improves anesthesia billing performance.

BACKGROUND: Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors. METHODS: Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The software's efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey. RESULTS: After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0+/-0.1 days to 1.1+/-0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification. CONCLUSION: This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department's revenue by approximately $400,000 per year.

Anesthesia↗
PubMed2002

Clerkship directors' perceptions of the impact of HCFA documentation guidelines.

PURPOSE: Chart notes are used to support billing codes under the evaluation and management guidelines of the Health Care Financing Administration (HCFA), in addition to serving as a record of the visit. To better understand the effect of the HCFA documentation guidelines, the authors collected data on how the guidelines affect participation by university- and community-based faculty in clinical education programs. METHOD: In 2000, the authors sent six copies of their questionnaire to the associate deans of the 125 U.S. medical schools and requested they distribute them to all core clerkship directors. The questionnaire consisted of multiple-choice and short-answer questions regarding documentation of medical visits, participation of community-based faculty, understanding of HCFA documentation guidelines, and effects on education programs. RESULTS: The response rate was about 50%. Most of the 379 clerkship directors who responded (77%) stated they were aware the HCFA documentation guidelines include specifications regarding the role medical students can play and documentation of medical visits, and 64% indicated they were concerned the guidelines would affect their educational programs. Concerns included the loss of student independence and active participation in the patient care environment (37), time constraints and the changing balance between education and service (16), loss of faculty and decreased morale (11), and decreased quality of care for patients (7). CONCLUSION: Leaders of medical education must work to modify these guidelines to protect the quality of patients' care, while maximizing students' educational opportunity and participation.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

Evaluation and time documentation for the clinical nurse specialist.

This article introduces a time documentation tool designed to gather and record information on the many facets of the role of the CNS. A review of the literature provides background information on types of evaluation, time documentation, and the need for qualitative as well as quantitative accountability. Because existing tools did not meet the documentation needs of the authors, they designed a system that could accommodate six domains of the CNS role and provide a means to document quantitative and qualitative activities. Three CNSs pilot tested the tool for 2 months and provided a critique of the instrument for the authors. The evaluations have been summarized, and comments for individualization and frequency of use have been noted. Suggestions for future study include the need for measuring outcomes of care and documentation methods for qualitative interventions.

Documentation↗
PubMedDate not supplied

Development and initiation of computer generated documentation for burn patient care.

Burn care is costly, complex, and poorly reimbursed. Capturing evaluation and management codes is an essential step in obtaining reimbursement for services rendered. For surgeons used to billing on the basis of Current Procedural Terminology codes, this represents a significant paradigm shift. In an effort to document the care provided and increase compliance with billing standards, we created computerized history and physical examination notes and progress notes specifically for burn patients. Drop down menus are included to answer directed queries, which allows the majority of the documentation to be completed with a point and click of the mouse. The note is completed by the house staff except for the "assessment and plan," which are entered by the attending physician who reviews and then electronically signs the note. A log of electronically signed notes is generated weekly for billing purposes. The use of these computerized documents has been reviewed and approved by the coding and quality assurance specialists within our billing organization. We believe these tools maximize the efficiency of documenting burn patient care, while minimizing the effort necessary to comply with evaluation and management guidelines. The aim of this study was to test the new computerized method at our institution to see whether it would improve documentation for evaluation and management services provided to burn patients. The results prove that this new system accomplished the goal we had set.

Burn Units↗
PubMed1995

Poor hospital documentation of violence against women.

OBJECTIVE: This study sought to determine if violence against women is accurately documented in the trauma registry, and if poor documentation in the medical record is associated with incorrect coding in the registry. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We identified women aged 15 to 49 in the trauma registry of a regional medical center who had unintentional and intentional injuries over three years, and retrospectively reviewed their medical records to verify registry coding. MEASUREMENTS AND MAIN RESULTS: Of the 41 assault victims in the registry, 32 were verified by the medical record. Of the 87 unintentional injuries, only 28 were verified; 21 were assault victims according to the medical record, and for the remaining 38, the medical record was too vague to determine intentionality. Thus, the sensitivity of the trauma registry in documenting violence against women was only 57%. Injuries correctly coded in the registry had the details well documented in the medical record, whereas injuries incorrectly coded had poor documentation in the medical record. CONCLUSIONS: Violence against women often goes undocumented in hospital data systems.

Adolescent↗
PubMed1998

Documenting acute care nurse practitioner practice characteristics.

Acute care nurse practitioners are functioning in a health care system that is changing rapidly. Simultaneously, the ACNP role is evolving. It is imperative that ACNPs document practice characteristics to communicate effectively within the health care system. The purpose of this article is to describe the process of documenting ACNP practice. Content includes rationale for documenting ACNP practice characteristics, a description of types and sources of data to collect, a discussion of barriers to documentation, and a format for a documentation tool.

Acute Disease↗
PubMedDate not supplied

An interdisciplinary documentation performance improvement project.

An Interdisciplinary Documentation Performance Improvement Task Force was created to evaluate and revise the documentation system at an academic medical center. The primary goal of the documentation project was to establish a standardized documentation system that reflected interdisciplinary planning of care for all of the organization's inpatient populations. This article identifies the process used to revise and implement an interdisciplinary documentation system. Project implementation and outcomes as well as recommendations and future initiatives are included.

Academic Medical Centers↗
PubMed2007

A web-based system for students to document their experiences within six core competency domains during all clinical clerkships.

The authors describe the design and implementation of a new Web-based system that allows students to record important features of their clinical encounters during all 10 required clinical clerkships, document their learning experiences in six major competency domains, and generate detailed real-time reports for themselves and their clerkship directors. A new Web-based system, DMEDS (Dartmouth Medical Encounter Documentation System), accepts input from computers and PDAs. Its design permits students to describe their patients, learning sites, interactions with preceptors, and important aspects of their clinical encounters in all of our medical school's competency domains. Using a common format for all required clerkships, clerkship directors select specific items most relevant to their clerkships from a common menu and set learning targets for specific diagnoses and clinical skills. This new system was designed in the fall of 2003, tested in the spring of 2004, and implemented in all clerkships for the 2004 to 2005 academic year. During the first full academic year that DMEDS was used, students documented nearly 32,000 discrete student-patient-preceptor encounters, an average of between 21 and 120 clinical encounters per Year 3 clerkship. Highlights of the analysis of these initial data include the following: (1) insights into how educational targets are set, (2) the extent of site-to-site variation in clerkship experiences, (3) the epidemiology of patients' declining student involvement, and (4) student experiences in and understanding of the newer competency domains.DMEDS can be used in all clinical clerkships and can address student experiences in all competency domains. It provides substantial value to students, clerkship directors, preceptors, and medical school administrators. As secondary benefits, the authors found that DMEDS facilitates educational research and is readily adapted for use in residency and fellowship programs as well. Student feedback highlights the need to pay close attention to the time invested by students documenting their clinical encounters. Course directors must ensure that the benefits to students (such as knowledge of meeting learning targets and preceptors providing direct feedback to students) are transparent. Finally, for other schools contemplating the change to a competency-based curriculum with the use of a clinical encounter documentation system, the time required for both students and faculty to adopt and fully engage these major educational culture shifts seems to be at least several years.

Clinical Clerkship↗
PubMed2000

Evaluation of seizure observation and documentation.

This study evaluated seizure documentation after participants observed videotaped seizures to determine how their background (educational level, employment position, years of experience, practice frequency, and familiarity with epilepsy and seizures) and attributes of the seizures themselves affected their skill. Observer variables did not show significant differences when mean seizure rating scores of 348 documented seizures for 58 participants were compared. Combinations of variables were significant; certified nursing assistants (CNAs) with clinical seizure experience had significantly higher mean seizure rating scores than those without experience (p < .01). There were significant differences in the mean percentile scores for each seizure observed (p < .001). Seizures with excess motor activity had the highest scores. Most common observations for any seizure observed were location and description of movement. Participants had significantly higher scores when observing a seizure a second time (p < .001). Differences in education, employment position, and years of employment are not limiting factors in performing seizure observation and documentation for persons who have been trained and certified in the skill. Opportunities to periodically view seizures improved seizure observation and documentation. Because motor movement observations predominate seizure documents, seizure observation instruction should not only emphasize key observational details but also highlight less frequent observations, such as responsiveness, that may play a key role in seizure classification. Using videotaped seizures and a scoring tool are useful for initial training and certification as well as periodic retraining to maintain quality in the skill.

Child↗
PubMed2006

High-quality MRC document coding.

The mixed raster content (MRC) model can be used to implement highly effective document compression algorithms. MRC document coders are typically based on the use of a binary mask layer that efficiently encodes the text and graphic content. However, while many MRC-based methods can yield much higher compression ratios than conventional color image compression methods, the binary representation tends to distort fine document details, such as thin lines and text edges. In this paper, we propose a method for encoding and decoding the binary mask layer that substantially improves the decoded document fidelity of text and graphics at a fixed bit rate. This method, which we call resolution-enhanced rendering (RER), works by adaptively dithering the encoded binary mask, and then applying a nonlinear predictor to decode a gray level mask at the same resolution. Both the dithering and nonlinear prediction algorithms are jointly optimized to produce the minimal distortion rendering. In addition, we introduce a second method, interpolative RER (IRER), which incorporates interpolation into the MRC decoder. The IRER method increases the compression ratio by allowing a high-resolution document to be coded at lower resolutions. We present experimental results illustrating the performance of our RER/IRER methods and comparing them to some existing MRC-based compression algorithms.

Algorithms↗
PubMed2006

Restoring warped document images through 3D shape modeling.

Scanning a document page from a thick bound volume often results in two kinds of distortions in the scanned image, i.e., shade along the "spine" of the book and warping in the shade area. In this paper, we propose an efficient restoration method based on the discovery of the 3D shape of a book surface from the shading information in a scanned document image. From a technical point of view, this shape from shading (SFS) problem in real-world environments is characterized by 1) a proximal and moving light source, 2) Lambertian reflection, 3) nonuniform albedo distribution, and 4) document skew. Taking all these factors into account, we first build practical models (consisting of a 3D geometric model and a 3D optical model) for the practical scanning conditions to reconstruct the 3D shape of the book surface. We next restore the scanned document image using this shape based on deshading and dewarping models. Finally, we evaluate the restoration results by comparing our estimated surface shape with the real shape as well as the OCR performance on original and restored document images. The results show that the geometric and photometric distortions are mostly removed and the OCR results are improved markedly.

Algorithms↗
PubMed2005

Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation.

AIM: This paper reports a study of nurses' attitudes towards the use of nursing diagnoses in perioperative documentation and the factors affecting these attitudes. BACKGROUND: There are both international and national requests for nurses to move from natural language-based narrative documentation to electronic documentation and clinical use of nursing classifications. However, nurses' attitudes toward nursing classifications have not been widely studied. METHODS: A questionnaire was distributed to a purposive sample of perioperative nurses (n = 146) who had participated in clinical testing of nursing diagnoses. The response rate was 60% (n = 87). The data were collected in 2003. RESULTS: In general, nurses' attitudes toward nursing diagnoses were positive. Those over 40 years of age who had clinical experience from 10 to 19 years, postbasic nursing education and previous knowledge of nursing diagnoses were most positive in their attitudes. However, the use of nursing diagnoses in perioperative practice was not seen as either necessary or accurate in describing patients' problems. Furthermore, the documentation of perioperative routines was seen as time-consuming and frustrating. CONCLUSIONS: Nursing classifications should be included in both preregistration nursing curricula and in-service educational programmes to ensure theoretical knowledge of and practical skills in standardized clinical languages. The perioperative nursing diagnoses should be reviewed to fit better with clinical practice. In addition, current perioperative documentation practices should be reconsidered and updated as appropriate to address clinical requirements better.

Adult↗
PubMed2006

Nursing documentation audit--the effect of a VIPS implementation programme in Denmark.

AIM AND OBJECTIVES: The aim of this paper is to present a study describing nurses' adherence to the VIPS model by evaluating the quality of nursing assessment, and the quantity of completed nursing care plans. BACKGROUND: Numerous efforts have been made over the years to improve nursing documentation in Denmark. Hospitals have traditionally based nurses' charting on a rudimentary version of the nursing process and on Virginia Henderson's theory of human needs. In 2002-2004 the Copenhagen University Hospital, Rigshospitalet, introduced the Swedish VIPS model for nursing documentation. VIPS is an acronym for well being, integrity, prevention and safety, all of which are seen as major goals for nursing care. The model organizes nursing data according to a system of keywords, which facilitates storage and retrieval of data. DESIGN AND METHODS: The design in this part of the study was retrospective, wherein 50 journals from each of the departments of cardiology, neurology, oncology and urology were audited annually for three years using the Cat-ch-Ing instrument (n=600). All nursing journals were randomly selected by including the first 50 journals at each site given a specific date. RESULTS: The nursing documentation significantly improved during the course of the study. After the second year the participants used the keywords appropriately and correctly according to the VIPS model. Application of primary nursing increased during the study. Initial, ongoing and discharge patient status improved. The nurses' familiarity with nursing diagnoses, goals and interventions increased. CONCLUSIONS: The structured implementation programme significantly improved nursing documentation, and the simultaneous training of the entire nursing staff shows promise. The VIPS model has prepared the nurses for more complex computerized taxonomies and classification systems in the future by improving the nurses' analytical skills. Relevance to clinical practice. New strategies for improving nursing documentation have been demonstrated.

Adult↗
PubMed2005

The effect of a social work intervention to enhance advance care planning documentation in the nursing home.

OBJECTIVES: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. DESIGN: Controlled clinical trial. SETTING: New York City nursing home. PARTICIPANTS: One hundred thirty-nine newly admitted long-term care residents. INTERVENTION: Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. MEASUREMENTS: Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. RESULTS: Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). CONCLUSION: This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.

Advance Care Planning↗
PubMed1995

The quantity of cause-of-injury information documented on the medical record: an appeal for injury prevention.

OBJECTIVE: To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e-codes. METHODS: Quantitative "stages of information" were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause-of-injury information categories. RESULTS: Information was obtained from 109 patients. Only 46% of the cause-of-injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause-of-injury information. CONCLUSION: Emergency providers obtain significantly less cause-of-injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause-of-injury information than was obtained during the patient interview.

Connecticut↗
PubMed2006

Effect of the introduction of a lumbar-puncture sticker and teaching manikin on junior staff documentation and performance of paediatric lumbar punctures.

BACKGROUND: Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post-lumbar-puncture complications in this age group. AIMS: To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months. SETTING: The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia). PARTICIPANTS: Paediatric emergency staff, including residents, registrars and consultants. METHODS: Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar-puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA). RESULTS: Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p<0.01, 95% confidence interval 6 to 8). CONCLUSIONS: The introduction of a lumbar-puncture proforma and formal teaching sessions using a paediatric manikin led to a marked improvement in the documentation of paediatric lumbar-punctures. Lumbar-punctures can be performed only by accredited medical officers who have achieved competency on the lumbar-puncture teaching manikin.

Child↗
PubMed2000

Push or be punished: tobacco industry documents reveal aggression against businesses that discourage tobacco use.

OBJECTIVE: To learn how the tobacco industry reacted to businesses' voluntarily enacting policies to discourage tobacco use and minimise exposure of employees and patrons to secondhand smoke. DATA SOURCES: Internal tobacco industry documents discovered among those posted on the internet. Approximately 24 million documents have been posted as of this writing. Information in this article was culled from among these documents, which have been made public as a unique requirement of the state of Minnesota's settlement with the industry. STUDY SELECTION: Those documents were used that offered insight into, and which gave a perspective on, the industry's attitudes and reactions toward other businesses as they adopted tobacco-free policies. CONCLUSIONS: In the wake of widespread acceptance that tobacco use causes illness and death, many individual businesses (and even entire industries) took positive steps to eliminate employees', customers', and facilities' exposure to tobacco smoke. Steps were also taken to discourage tobacco use among employees. Internal tobacco industry documents show that the industry reacted with aggression, and in some cases with retribution, against businesses that voluntarily adopted policies to discourage tobacco use. The intent of these actions appears to be to reverse these policies, with a broader goal of neutralising large scale public and private trends that reflect the decreasing social acceptability of tobacco use.

Attitude↗