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At least 397 records · Page 22Linked to original sources
PubMed2000

Documentation of rectal examination performance in the clinical teaching unit of a university hospital.

Digital rectal examination is used to evaluate the distal rectum and other organs, including the prostate gland. It may be combined with fecal screening for occult blood loss, and annual performance has been recommended for asymptomatic individuals over age 40 years for cancer screening. In this study, documentation of digital rectal examinations was assessed through a review of hospital medical records of a randomly selected group of 100 patient discharges (55 females and 45 males) from a total of 896 patients admitted through a hospital emergency room to a medical clinical teaching inpatient unit of a university hospital during a six-month period. In this group, 26% were admitted for a gastrointestinal disorder, but only 17% of all hospitalized patients had rectal examinations done by the medical resident house staff and/or attending medical staff directly responsible for the care of these patients. Occult blood testing was done in 15 patients. Pelvic and breast examinations were rarely documented. The majority of rectal examinations (ie, 13 of 17) were 'same sex' examinations, appeared to be used largely for testing or confirmation of grossly visible blood loss and were never confirmed by attending staff. The presence or absence of nursing staff during examinations was not documented. The prostate examination was normal in one patient but not documented in the other 44 males (ie, 26 patients over age 60 years). In conclusion, rectal examinations (as well as breast and pelvic examinations) were rarely documented in the medical teaching unit by medical resident house staff or their attending staff.

Adolescent↗
PubMed2002

Evaluation of immediate discharge documents--room for improvement?

BACKGROUND: The Immediate Discharge Document is a tool used to communicate patient discharge information between hospitals and general practitioners. The standard of information provided may be variable, and sometimes delayed in arriving at the GP practice. Typed communication from the hospital can also be slow. This can result in difficulty managing patients in the community following their discharge. Our aim was to assess the quantity of information provided on Immediate Discharge Documents, and to assess the time scale taken for GPs to receive written communications from hospitals regarding patient discharges. An audit was initiated using a tool devised from Scottish Intercollegiate Guidelines Network Publication no 5 and involving four general practices within City of Perth, Scotland. Data was collected over a 28-day period in June/July 2001, by examining Immediate Discharge Documents relevant to each practice population received during this period, and by noting the time of arrival of a final typed summary. Data was analysed by Tayside Audit Resource for Primary Care. A total of 244 Documents were audited. Most significant results include basic administrative detail lacking in up to 30%. Of total documents, 13% failed to record a main condition or diagnosis; 93% recorded drug information, but only in 28% were follow up plans clear; 60% were received within five days of discharge, whilst final typed summaries were received from the hospitals within four weeks only in 51%. CONCLUSION: These results show there to be room for improvement with regard communication of patient discharge information, in regard to both the content of information provided and the time it takes to arrive. We require to raise awareness of this problem amongst hospital colleagues involving clinical governance and audit staff, with the objective to improve the quality and timescale of information transfer. WHERE THIS PIECE FITS: It is known that effective information transfer between health professionals is vital to optimise patient care. This work gives further impetus to improve the current standard of communication, and confirms a significant time delay that it takes information to reach GPs from the hospital setting.

Continuity of Patient Care↗
PubMed1988

Documenting the clinical pharmacist's activities: back to basics.

The profession of pharmacy has applied the term "documentation" to count activities that more closely approximate descriptive protocols or administrative reports. This extended nonclinical use of the term documentation has resulted in the profession losing sight of a necessary step in the development, justification, and successful implementation of clinical pharmacy services. An instrument that helps to standardize the documentation of a clinical pharmacist's database, patient-care activities, and therapeutic plans is presented. This process, the pharmacist's workup of drug therapy (PWDT), consists of the following six interrelated steps: (1) establish a comprehensive patient-specific database; (2) identify patient-specific, drug-related problems; (3) describe desired therapeutic outcomes; (4) list all therapeutic alternatives that might produce the desired outcomes; (5) select the drug recommendation(s) that most likely will result in the desired outcomes; and (6) establish a plan for therapeutic drug monitoring that documents that desired effects occur and undesired effects are minimized. A formative method of documenting the clinical pharmacist's activities such as the PWDT must be functional on a daily basis in order to generate meaningful summative management reports.

Documentation↗
PubMed2001

Computerized clinical documentation system in the pediatric intensive care unit.

BACKGROUND: To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity. METHODS: Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design. RESULTS: With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. CONCLUSIONS: When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs.

Child↗
PubMed2006

House officer procedure documentation using a Personal Digital Assistant: a longitudinal study.

BACKGROUND: Personal Digital Assistants (PDAs) have been integrated into daily practice for many emergency physicians and house officers. Few objective data exist that quantify the effect of PDAs on documentation. The objective of this study was to determine whether use of a PDA would improve emergency medicine house officer documentation of procedures and patient resuscitations. METHODS: Twelve first-year Emergency Medicine (EM) residents were provided a Palm V (Palm, Inc., Santa Clara, California, USA) PDA. A customizable patient procedure and encounter program was constructed and loaded into each PDA. Residents were instructed to enter information on patients who had any of 20 procedures performed, were deemed clinically unstable, or on whom follow-up was obtained. These data were downloaded to the residency coordinator's desktop computer on a weekly basis for 36 months. The mean number of procedures and encounters performed per resident over a three year period were then compared with those of 12 historical controls from a previous residency class that had recorded the same information using a handwritten card system for 36 months. Means of both groups were compared a two-tailed Student's t test with a Bonferroni correction for multiple comparisons. One hundred randomly selected entries from both the PDA and handwritten groups were reviewed for completeness. Another group of 11 residents who had used both handwritten and PDA procedure logs for one year each were asked to complete a questionnaire regarding their satisfaction with the PDA system. RESULTS: Mean documentation of three procedures significantly increased in the PDA vs handwritten groups: conscious sedation 24.0 vs 0.03 (p = 0.001); thoracentesis 3.0 vs 0.0 (p = 0.001); and ED ultrasound 24.5 vs. 0.0 (p = 0.001). In the handwritten cohort, only the number of cardioversions/defibrillations (26.5 vs 11.5) was statistically increased (p = 0.001). Of the PDA entries, 100% were entered completely, compared to only 91% of the handwritten group, including 4% that were illegible. 10 of 11 questioned residents preferred the PDA procedure log to a handwritten log (mean +/- SD Likert-scale score of 1.6 +/- 0.9). CONCLUSION: Overall use of a PDA did not significantly change EM resident procedure or patient resuscitation documentation when used over a three-year period. Statistically significant differences between the handwritten and PDA groups likely represent alterations in the standard of ED care over time. Residents overwhelmingly preferred the PDA procedure log to a handwritten log and more entries are complete using the PDA. These favorable comparisons and the numerous other uses of PDAs may make them an attractive alternative for resident documentation.

Computers, Handheld↗
PubMed2005

Documentation of individualized patient care: a qualitative metasynthesis.

The aim of this study was to increase understanding of how individual patient care and the ethical principles prescribed for nursing care are implemented in nursing documentation. The method used was a metasynthesis of the results of 14 qualitative research reports. The results indicate that individualized patient care is not visible in nurses' documentation of care. It seems that nurses describe their tasks more frequently than patients' experiences of their care. The results also show that the structure of nursing documentation and the forms or manner of recording presupposed by the organization may prevent individual recording of patient care. In order to obtain visibility for good patient-centred and ethical nursing care, an effort should be made to influence how the content of nursing care is documented and made an essential part of individual patient care. If the content of this documentation does not give an accurate picture of care, patients' right to receive good nursing care may not be realized.

Attitude of Health Personnel↗
PubMed2004

Where's the beef? The promise and the reality of clinical documentation.

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.

Documentation↗
PubMed2005

Adequacy of online medical command communication and emergency medical services documentation of informed refusals.

BACKGROUND: In the out-of-hospital setting, when emergency medical services (EMS) providers respond to a 9-1-1 call and encounter a patient who wishes to refuse medical treatment and/or transport to the hospital, the EMS providers must ensure the patient possesses medical decision-making capacity and obtain an informed refusal. In the city of Cleveland, Ohio, Cleveland EMS completes a nontransport worksheet that prompts the paramedics to evaluate specific patient characteristics that can influence medical decision-making capacity and then discuss the risks of refusing with the patient. Cleveland EMS then contacts an online medical command (OLMC) physician to authorize the refusal. OLMC calls are recorded for review. OBJECTIVES: To assess the ability of EMS to determine medical decision-making capacity and obtain an informed refusal of transport. METHODS: This study was a retrospective review of a cohort of recorded OLMC refusal calls and of the accompanying written documentation by Cleveland EMS. The completeness of the verbal communication between the paramedic and OLMC physician and the written documentation on the nontransport worksheet were measured as surrogate markers of the adequacy of determining medical decision-making capacity and obtaining an informed refusal. RESULTS: One hundred thirty-seven OLMC calls for patient-initiated refusals were reviewed. Vital signs and alertness/orientation were verbally communicated more than 83% of the time. The presence of head injury, presence of alcohol or drug intoxication, and presence of hypoglycemia were verbally communicated less than 31% of the time. Verbal communication stating that the risks of refusing had been discussed with the patient occurred 44.5% of the time. The written documentation of the refusal encounter was more complete, exceeding 95% for vital signs and alertness/orientation, and exceeding 80% for the remaining patient characteristics. The rate of written documentation that the risks of refusing had been discussed with the patient was 48.7%. Discrepancies between the verbal and written paramedic reports were clinically insignificant. CONCLUSIONS: Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.

Adolescent↗
PubMed2000

Development of a new approach to palliative care documentation.

Efficient, comprehensive documentation is a vital element of all healthcare provision. It not only provides a record of care, but should reflect the quality of that care, enable continuity of care between practitioners and reinforce care standards. However, documentation in palliative care often falls short of these ideals. This article describes the formulation of an integrated system of documentation which aims to address the failings of documentation procedures in one hospice/palliative care unit. The resulting system seeks to embody the rationale of palliative care within a dynamic, patient-centred approach to nursing documentation.

Documentation↗
PubMed2005

Nursing documentation: non-physical dimensions of end-of-life care in acute wards.

AIM: to explore discrepancies between nurses' knowledge and their documentation of issues of psychosocial, spiritual and cultural aspects of palliative care, evidenced clearly in recent nursing research into end-of-life care in an acute care, teaching hospital. DESIGN: the study involved a retrospective patient case-note audit of an opportunistic sample of 20 patients deceased recently and interviews of the two nurses most involved in the care of each patient (n=40). FINDINGS: this research indicates that nurses in acute care settings often recognize, sometimes explore, but infrequently document psychosocial, spiritual and cultural aspects of care. CONCLUSION: there is a strong need for: (1) education about both the impact of non-physical dimensions of patients' lives and the effective documentation of these dimensions; and (2) up-grading of documentation tools to better facilitate documentation of non-physical aspects of palliative care.

Adaptation, Psychological↗
PubMed2006

[Implementation of the multi-center basis documentation CL-BaDo for conciliar and liaison services: generating data for internal quality management and cost calculation].

In the German DRG system the funding of CL services is not ensured. The documentation of psychiatric comorbidity and CL care delivery is a pre-condition to the development of funding models for CL-services. A task force of several German psychosomatic associations (German College of Psychosomatic Medicine, German Society of Psychosomatic Medicine and Psychotherapy, General Medical Society for Psychotherapy) developed a new documentation form for CL-services (CL-BaDo). The pilot study explored the multicenter implementation of CL-BaDo and the use of the documentation form for quality management and cost calculation. Over a period of at least three months, participating CL-services documented all CL cases consecutively with the CL-BaDo. One site applied full electronic data processing. 2116 CL cases from eight psychosomatic CL-services were analysed. The CL-BaDo is a time-efficient, feasible and acceptable documentation form for CL-service delivery. The full electronic data processing enables networking with a hospital information system to produce higher data quality. The data of CL-BaDo can be used locally for quality management, development of management strategies and communication with consultants, as well as nationwide for health policy questions and research.

Austria↗
PubMedDate not supplied

Implementing personal digital assistant documentation of pharmacist interventions in a military treatment facility.

OBJECTIVE: To describe the use of personal digital assistants (PDAs) in documenting pharmacists' clinical interventions. SETTING: Evans Army Community Hospital (EACH), a 78-bed military treatment facility, in Colorado Springs. PARTICIPANTS: Pharmacists on staff at EACH. PRACTICE DESCRIPTION: All pharmacists at EACH used PDAs with the pilot software to record interventions for 1 month. The program underwent final design changes and then became the sole source for recording pharmacist interventions. The results of this project are being evaluated every 3 months for the first year and yearly thereafter. PRACTICE INNOVATION: Visual CE (Syware Inc. Cambridge, Mass.) software was selected to develop fields for the documentation tool. This software is simple and easy to use, and users can retrieve reports of interventions from both inpatient and outpatient sections. The software needed to be designed so that data entry would only take a few minutes and ad hoc reports could be produced easily. MAIN OUTCOME MEASURES: Number of pharmacist interventions reported, time spent in clinical interventions, and outcome of clinical intervention. RESULTS: Implementing a PDA-based system for documenting pharmacist interventions across ambulatory, inpatient, and clinical services dramatically increased reporting during the first 6 months after implementation (August 2004-February 2005). After initial fielding, clinical pharmacists in advanced practice settings (such as disease management clinic, anticoagulation clinic) recognized a need to tailor the program to their specific activities, which resulted in a spin-off program unique to their practice roles. CONCLUSION: A PDA-based system for documenting clinical interventions at a military treatment facility increased reporting of interventions across all pharmacy points of service. Pharmacy leadership used these data to document the impact of pharmacist interventions on safety and quality of pharmaceutical care provided.

Computers, Handheld↗
PubMed1994

Science at Harvard University, 1846-47: a case study of the character and functions of written documents.

This paper explores surviving documentation and what it reveals about the underlying social structure and relations in a historic time and place. The mid-nineteenth century is chosen as a period prior to modern bureaucracies so that documents are not found in defining filing systems. Some six hundred documents are studied individually and characterized collectively. They are examined not to tell a story, however, but for evidence of their creation and maintenance and of their physical types, functional characteristics, and relations between authors and recipients. The study reveals the fruitfulness of such an orientation to documents, which complements traditional historical uses that emphasize document content.

Documentation↗
PubMed1990

Documenting concurrent clinical pharmacy interventions.

The documentation of clinical pharmacy activities is an important issue and the authors describe a relatively simple and easily implemented method of documenting concurrent clinical pharmacy interventions. This quality assurance measure was added to the quality assurance calendar of a tertiary care medical center/teaching hospital to: (1) document to the Joint Commission on Accreditation of Healthcare Organizations that the pharmacy department is involved in direct patient care, and (2) demonstrate to hospital administrators that pharmacists are an integral and necessary component of the health care team. At least 115 of 428 (27%) documented interventions during 1988 prevented patients from suffering potentially serious side effects and adverse drug reactions. Physicians and nurses initiated consultations by contacting pharmacists, either by phone or in person, and asking them to: (1) recommend dosages for renally impaired patients; (2) monitor patients receiving medications such as aminoglycosides, digoxin, and phenytoin; (3) suggest appropriate doses for specific indications; (4) recommend a formulary drug for a specific condition; and (5) provide drug information. Pharmacists initiated consultations by contacting physicians and nurses, either by phone or in person, to clarify an order or make recommendations regarding drug therapy. Nurses, pharmacists, and physicians initiated 37%, 33%, and 30% of the clinical interventions, respectively. Most of the physician (89%) and nurse (82%) initiated interventions were requests for drug information, whereas most of the pharmacist initiated interventions were order clarifications (51%). The daily documentation of clinical pharmacy interventions demonstrated that the quality of patient care and patient outcome was improved and served as an effective method of cost-justifying pharmacist positions in this era of fiscal constraints.

Concurrent Review↗
PubMed1991

Documentation of drug interchange in the medical record.

The hospital medical record has become increasingly exposed to retrospective audits by third party insurers, quality assessment studies, and billing inquiries. As a result, the demand for complete documentation in the record has steadily increased during the past few years. Institutional medical practices are subject to a variety of regulations and standards. Economic pressures are continually exerted on hospitals for cost reduction measures, which include patient drug costs. While hospitals have engaged in a variety of methods of drug interchange to reduce costs, documentation procedures for interchange are not specifically regulated. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) appears to be the only source for applicable regulations regarding medical record documentation. With respect to therapeutic drug interchange, few guidelines exist to "legalize" this common practice. A procedure to provide the physician's informed consent for therapeutic interchange is explained. This article will focus on drug interchange notification procedures for non-teaching community hospitals. Legalities, practicalities, and regulations for medical record documentation are addressed. In addition, suggestions for the documentation of drug interchange are proposed.

Documentation↗
PubMed1995

Development of a comprehensive clinical pharmacy workload documentation system.

The purpose of this project was to develop a workload documentation system which captures the clinical activities of the pharmacist, as well as the pharmacist's impact on the patient's drug therapy outcomes and costs. The documentation system consists of three sections: clinical activities, clinical effectiveness indicators, and cost-effectiveness indicators. In addition to those established by the National Hospital Productivity Improvement Program-Pharmacy Workload Measurement System, other indicators are incorporated to more accurately reflect the pharmacists' daily clinical activities. Clinical effectiveness indicators of patient outcomes include the number and type of drug-related problems identified and resolved and the number of therapeutic interventions made and accepted. Cost-effectiveness is measured by pharmacists' interventions on 14 focused areas of drug therapy. Compliance with daily documentation is facilitated by use of pocket-sized cards for data collection and retrieval. This documentation system has been implemented since December 1990. Quarterly reports submitted to the Director identify changes and trends in workload. Information is used for staff justification, impact assessment of clinical service provided, identification of needs for staff development and planning future clinical directions. In order to enhance the efficiency of documentation and data analysis, future plans include computerization and evaluation of the frequency of data collection.

Clinical Pharmacy Information Systems↗
PubMed1991

Effects of a surgical case review handbook on chart documentation.

The study results demonstrated statistically significant improvement in chart documentation after handbook distribution for the residents (t = 5.67, p.05). Improvement was made in the attending group after distribution of the handbook relative to documentation, but it was not statistically significant. The attending physicians showed a reduction of 1.2 percent in the mean percentage of documentation errors per month after use of the handbook, whereas the residents showed a reduction of 5.0 percent. The new residents (first-year) reached levels of chart documentation comparable to the more senior residents (second- and third-year) within three months after handbook distribution. During the study period, no interventions or efforts were made other than distribution of the handbook. Therefore, it can be concluded that the handbook produced an improvement in chart documentation compliance for all physicians, with a statistically significant effect for the resident physicians. The results indicate a high potential benefit for the first-year residents in particular.

Alabama↗
PubMed1998

Computer-aided documentation and therapy planning in pediatric oncology.

In the past 20 years considerable progress was made in pediatric oncology concerning the results of therapy in Germany. Nationwide multicentre trials provide protocols for the therapy of the children. The calculation of the chemotherapy according to the protocols is rather complex and the documentation efforts for the pediatricians are enormous. Thus, we developed as a first step an application system for Computer Aided Therapy Planning In Pediatric Oncology (CATIPO), that is in routine use in about 20 pediatric clinics in Germany. In order to support the physician comprehensively with the documentation that is necessary for the trials we currently develop a Documentation System for Pediatric Oncology (DOSPO) that comprises the functionality of chemotherapy planning according to the protocols released by the trial centres. Besides supporting the physician in clinical routine the major objective is to improve the quality of the documented data. To reach this aims DOSPO combines research aspects of decision support and clinical documentation: formal representation of general protocols, calculating of a particular therapy for a patient, data acquisition, communication interfaces for transferring the data to the trial centres. In order to support trial centres an authoring system and a central data dictionary will be developed. This will enable the trial centres to develop new modules for trial-specific data acquisition in the clinics.

Antineoplastic Combined Chemotherapy Protocols↗