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Combining dictionary techniques with extensible markup language (XML)--requirements to a new approach towards flexible and standardized documentation.

In oncology various international and national standards exist for the documentation of different aspects of a disease. Since elements of these standards are repeated in different contexts, a common data dictionary could support consistent representation in any context. For the construction of such a dictionary existing documents have to be worked up in a complex procedure, that considers aspects of hierarchical decomposition of documents and of domain control as well as aspects of user presentation and models of the underlying model of patient data. In contrast to other thesauri, text chunks like definitions or explanations are very important and have to be preserved, since oncologic documentation often means coding and classification on an aggregate level and the safe use of coding systems is an important precondition for comparability of data. This paper discusses the potentials of the use of XML in combination with a dictionary for the promotion and development of standard conformable applications for tumor documentation.

Documentation↗

The development of pressure ulcers in patients with hip fractures: inadequate nursing documentation is still a problem.

The aims of the study were to investigate, on a daily basis: (i) the development and progress of pressure ulcers, (ii) the documented nursing interventions for prevention and treatment of pressure ulcers, and (iii) when nursing interventions regarding prevention and treatment of pressure ulcers were documented, in relation to patient risk status and the development of pressure ulcers. The study design was prospective, comparative and descriptive. A total of 55 patients with hip fracture were included. To facilitate the nurse's assessment, a 'pressure ulcer card' was developed, consisting of the Modified Norton Scale (MNS) and descriptions of the four stages of pressure ulcers. The incidence of pressure ulcers was 55%. The mean rank of the lowest MNS score was significantly lower for patients who developed pressure ulcers than for patients without pressure ulcers. The majority of the pressure ulcers occurred between admission to the ward and the fourth day after surgery. Documented interventions regarding prevention and treatment were: repositioning, overlays, cushions, use of lotion and observation. The mean number of interventions per patient was 2.2 for patients who developed pressure ulcers during their hospital stay. The comprehensiveness and quality of the nursing record was unsatisfactory, and only three nursing records reached the level required by Swedish law. Preventive interventions such as repositioning were documented when the pressure ulcer had already occurred. The lack of nursing documentation regarding prevention and treatment of pressure ulcers may indicate that nurses did not identify pressure ulcers as a prioritized nursing problem for this patient group. The Modified Norton Scale could be a valuable tool for nurses, both identifying the patient at risk and acting as a guide for nursing interventions. The study was approved by the ethics committee of the Faculty of Medicine at Uppsala University.

Aged↗

Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. Health Care Financing Administration.

BACKGROUND: Documentation guidelines have been developed by the Health Care Financing Administration (HCFA) to promote consistent selection of physician evaluation and management (E & M) codes. Our goals were to determine whether medical providers and auditors agree in their assignment of office codes using 1995 and 1998 guidelines and to ascertain if the code levels assigned are affected by auditor experience and training. METHODS: A total of 1,069 established patient charts from private family physician offices were reviewed by a family practice faculty physician, a family practice resident physician, and a professional coder. The main outcome measures were the agreement between the auditors and the medical care provider on code selection and the degree to which documentation supported the code selected. RESULTS: All auditors agreed with the medical provider code selection in only 15.2% (1995 guidelines) and 29.2% (1998 guidelines) of visits. Professional coders were more likely than faculty physicians or resident physicians to agree with the code assigned by the medical provider (51.7% vs 40.7% and 39.6%, P <.001). Documentation adequately supported the most common office code selection, 99213, in 92.7% (1995) and 91.0% (1998) of the charts reviewed. Concurrence among all auditors was only 31.0% (1995) and 44.3% (1998). CONCLUSIONS: Interobserver differences exist in the assignment of E & M codes by auditors using both 1995 and 1998 HCFA guidelines. The 1998 documentation guidelines produce greater agreement among auditors. The documentation supported the level of code billed in the majority of established patient office visits.

Ambulatory Care↗

Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital.

Economic pressures on healthcare systems have intensified the necessity of demonstrating the unique contribution of nursing care to patient outcomes. The use of nursing information systems (NIS) has increased completeness of some nursing documentation elements. This study's purpose was to evaluate differences in documentation completeness of nurse assessments of patient outcomes (NASSESS), achievement of patient outcomes (NGOAL), nursing interventions done (NQUAL), and routine assessments before and after implementation of an NIS in a 100-bed urban university hospital in west Tennessee and before and after retraining in NIS use and care planning. NIS implementation did not improve documentation within the first six months. However, retraining and continued NIS use did significantly improve NASSESS, NGOAL, NQUAL, and blood pressure documentation 18 months postimplementation. Nurses must evaluate documentation completeness before and periodically after NIS implementation, using results to improve patient record data validity for patient care decisions, quality improvement, and research.

Acute Disease↗

Accurate documentation equals quality patient care.

Accurate nursing documentation has a central role in both quality care and revenue issues facing hospitals today. However, it is often difficult to complete documentation when nurses are faced with the completion of multiple care issues. This problem is no more evident than in the operating room. Comprehensive documentation requires not only time and effort on the nurse's part, but a dedication and belief in its imperative. Nurses must always keep in mind that the "results and benefits of nursing documentation are greater than the sum of the task itself. Documentation IS quality patient care".

Boston↗

Influence of structured encounter forms on documentation by community pediatricians.

BACKGROUND: Age-specific structured encounter forms for well-child examinations have been shown to improve thoroughness of documentation among pediatric house staff. This study evaluated the influence of such forms on completeness of documentation by practicing pediatricians. METHODS: In this before-after trial at 5 urban community health clinics, participants were 8 pediatricians practicing for at least 1 year. Brief group training sessions on use of the forms were provided to the participating physicians. Completeness of documentation was defined as the proportion of elements from a full well-child examination recorded in the medical record. RESULTS: After introduction of the standardized forms, completeness of documentation significantly increased for all components. CONCLUSIONS: The use of age-specific structured encounter forms improved the completeness of documentation of pediatric well-child examinations done by pediatricians.

Analysis of Variance↗

Documentation of preventive education and screening for osteoporosis.

The purpose of this study was to identify provider documentation practices related to osteoporosis prevention and screening for women aged 40 to 65 years and to determine whether documentation practices differ by type of provider. The setting was an obstetric/gynecologic clinic of a large metropolitan health maintenance organization in Minnesota. One hundred fifty medical records were reviewed for documentation addressing calcium intake, vitamin D intake, exercise, hormone replacement therapy (HRT), and bone mineral densitometry. A statistically significant difference was found between physicians and advanced practice nurses in the documentation of vitamin D and HRT as osteoporosis prevention strategies. The results of this study suggest a need for increased awareness on the part of providers about the importance of their comprehensive documentation of counseling and education interventions as one strategy to promote positive outcomes such as osteoporosis prevention.

Adult↗

Documenting procedures and deliveries during family practice residency: a survey of graduates' experiences, preferences, and recommendations.

BACKGROUND AND OBJECTIVES: The University of Washington Family Practice Residency Network (UW Network) is in the process of implementing a Palm Pilot-based procedure and delivery documentation system throughout 16 residency programs. Our study examined the experiences of past UW Network graduates in obtaining hospital privileges and in documenting procedures and deliveries. METHODS: A survey was mailed to 201 1999 and 2000 UW Network graduates, asking them questions about their experiences obtaining hospital privileges after graduation and documenting procedures and deliveries during their training. RESULTS: A total of 124 surveys (62% response rate) were analyzed. Ninety-four percent of the respondents had applied for hospital privileges, and 84% received all the privileges they requested. Forty-four percent indicated they had to provide some written documentation to get hospital privileges, but only 7% had to provide more than a numeric total of procedures or deliveries. Respondents predominantly used log cards and Palm Pilots for data collection. Palm Pilots were preferred over log cards, and the Palm Pilot systems received higher satisfaction ratings. CONCLUSIONS: For the majority of graduates, detailed delivery and procedure information was not necessary to obtain hospital privileges. Nevertheless, there are other reasons to document training experiences, and graduates strongly advise family practice residents to record their procedure and delivery experiences. Family practice residency programs should consider giving house staff handheld computers to record the procedures they perform.

Adult↗

A survey of residents' attitudes and practices in screening for, managing, and documenting domestic violence.

OBJECTIVE: We conducted this study to identify residents' limitations in screening for, documenting, and managing domestic violence (DV) and to focus future educational interventions. METHODS: We administered a detailed survey to 103 internal medicine residents from 4 university-affiliated programs to ascertain their attitudes about and practices in screening for, documenting, and managing DV. RESULTS: Most residents agreed that DV is a significant health care problem (87%) and one in which physicians can intervene effectively (77%), yet 37% reported not screening for DV. Residents who said they do not screen reported a variety of mitigating factors, from uncertainty about how to screen for and manage DV, to fear of insulting or angering the patient. Eighty-two percent stated that they would document DV in the chart, but 51% had reasons for not documenting DV, ranging from fear that the patient's partner might harm the patient or the physician to concern that the patient may not be telling the truth. Fifty-seven percent of residents said they would ask about DV more often if state law mandated it. When asked to choose which management interventions were helpful or unhelpful, many residents made incorrect, potentially injurious choices. CONCLUSION: Many residents reported beliefs and practices that could inhibit optimal care of DV victims. Educational interventions should be directed at remedying residents' gaps in knowledge and attitudes to improve screening for, documenting, and managing DV.

Adult↗

Guideline based structured documentation: the final goal?

Structured documentation of medical procedures facilitates information retrieval for research and therapy and may help to improve patient care. Most medical documents until today however consist mainly of unstructured narrative text. Here we present an application for endoscopy which is not only fully integrated into a comprehensive clinical information system, but which also supports various degrees of structuring examination reports. The application is used routinely in a German University hospital since summer 2000. We present the first unstructured version which permits storage of a free text report together with selected examination images. The next step added improved structure to the document using a catalogue of index terms. The practical advantages of selective patient retrieval are described. Today we use a version which supports fully structured, guideline based documentation of endoscopy reports in order to automatically generate essential classification codes and the narrative examination report All versions have advantages and disadvantages and we conclude that guideline based documentation may not be suitable for all endoscopy cases.

Documentation↗

A generic interface to XML documents for guidance information.

We present a generic means of interfacing XML documents and clinical systems. The interface has been developed to allow the integration of best practice guidance information within prescribing systems. The interface has the following characteristics: (1) integrating developers do not have to interpret the structure of the XML documents, (2) inconsistencies between integrations are reduced, (3) the structure of the XML documents can change without affecting integration and (4) specification and documentation of the NDR document interface is within the interface itself.

Documentation↗

Documentation of care in an oncology outpatient setting.

Finding time to perform thorough documentation in a busy oncology outpatient setting is an increasingly difficult task. This article describes the development of a new documentation system designed for an oncology outpatient unit. The system consists of a set of documentation tools that are specific for the type of patient visit, an initial assessment form, and guidelines for using the forms. The system was developed to reduce the amount of nursing time spent on documentation and to improve the quality of the documentation. Evaluation of the system indicated that the forms decreased charting time by 50%. Suggestions for modifying and revising the tools are included. This system could be adapted for use in any ambulatory oncology setting.

Documentation↗

Documentation and the transfer of clinical information in two aged care settings.

BACKGROUND: Increasingly, documentation, both formal and informal, is being undertaken by nurses using a range of modalities. In Australia there is a sense that the demand for this in the aged care sector is increasing in line with requirements of funding agencies. However, the scope of this activity and its impact on nursing workload in aged care facilities has not been rigorously investigated. Funding of aged care facilities in the public hospital system in Australia is dependent on documentation of care. OBJECTIVE: The purpose of this study was to determine the frequency and time of day that documentation and transfer of clinical information activities occurred for nurses of all skill levels in two aged care facilities in New South Wales, Australia. DESIGN: Work sampling of direct care, indirect care, unit-related activities and personal time. SETTING: Two hospitals with aged care facilities near Sydney, Australia. SUBJECTS: One hundred and six nurses. RESULTS: 16,395 observations of nursing activities were recorded. The transfer of clinical information between health care professionals comprises a large part of the nurse's working day. It comprised between 37 and 38% in this study, but the time of day in which it took place differed between the two hospitals. CONCLUSION: Documentation needs to be seen as an integral part of care by managers and clinicians. Both would wish to ensure that it is undertaken in the most efficient and effective manner to allow the necessary time for direct care. More detailed understanding may allow clinical unit managers to re-structure the workday in terms of documentation to achieve greater efficiencies or effective use of nursing time.

Communication↗

Development of a nursing automated documentation system.

As hospital length of stay has decreased and patient acuity has increased, the nurse is confronted daily with the challenge of managing time between patient care and documentation. Documentation of care has consistently been a time-consuming and frustrating part of nursing practice. The nursing shortage has only compounded this problem. St. Joseph's Hospital has creatively begun to facilitate documentation by developing a Nursing Automated Documentation System (NADS) in collaboration with CliniCom, Inc. of Boulder, Colorado. This article documents the development and implementation of the system.

Documentation↗

Nursing documentation: a format not a form.

Nurses have a difficult time committing themselves to the documentation of patient care. Various forms, assessment sheets, and checklists have been created only to prove ineffectual or to be discarded. Our format allows for the documentation of health status and permits nurses to document in the style with which they are most comfortable. The format is designed to elicit critical information and to reflect the hospital's established nursing practice standards. Subjective and objective evaluations conducted over a three month period demonstrated an appreciation for the format, a marked increase in nursing documentation, and a strong commitment by the nursing staff to reflect nursing practice in nursing documentation. A format not a form-is a method that has proven successful.

Boston↗

Clinical audit and standardised follow up improve quality of documentation in diabetes care.

AIM: High quality of follow up data is important in improving diabetes care. Our aim was to improve quality of documentation and diabetes care by using a combination of clinical audit and standardised follow up. METHODS: During 2 months in 1991-2 the records of all patients attending the diabetes clinic were reviewed. Quality of documentation was assessed for diabetic medication, hypoglycaemia, glycoprotein level, body weight, smoking history, blood pressure, albuminuria, visual acuity, fundi examination, neuropathy, foot inspection, peripheral vascular disease, cerebrovascular disease, ischaemic heart disease and serum cholesterol. For all parameters results and documented interventions were noted. A standardised follow up form was then introduced and the audit was repeated in 1993-4. RESULTS: 156 patients were included in 1991-2 and 138 in 1993-4. There were no differences between the two groups with regards to baseline demographic data. Follow up data for 10 parameters were between 1.15 and 5.35 times more likely to have been recorded in 1993-4. The other 5 items were as likely to have been recorded in 1991-2 as in 1993-4. However, the differences between the two audits were less convincing and inconsistent for number of abnormalities detected in each group and whether abnormal results led to documented actions. CONCLUSIONS: These results show that repeated audit and standardised follow up can improve the quality of documentation of diabetic follow up, but that this does not necessarily mean that a higher proportion of abnormal results will be detected and acted upon. Additional practice protocols may be necessary to achieve this.

Diabetes Mellitus↗

A computerized system to improve documentation and reporting of pharmacists' clinical interventions, cost savings, and workload activities.

A major factor in delivering patient care is documenting activities by pharmacists. This documentation is not only essential to sustain existing programs but necessary to justify future growth of resources. A computerized documentation system for clinical interventions and workload activities was developed in a 340-bed university teaching hospital. With the expansion of its pharmaceutical care model, the department reworked its distribution process to allocate more pharmacist time for patient care. Manual documentation of these services, however, soon was identified as an obstacle. A software program was developed to alleviate the problems inherent with manual documentation. This "user-friendly" program tracks clinical recommendations and interventions by pharmacists, and calculates cost savings/avoidance. It also facilitates monthly and annual reporting for department managers.

Clinical Pharmacy Information Systems↗

Documentation and information services in the HELIOS project.

In a modern software project large amounts of documentation is produced. All parts of the complex software system require extensive documentation--both for reference purposes and promotional reasons. However, there are some aspects that often are forgotten or badly implemented; (i) the availability of on-line documentation, (ii) integration of the different formats of documentation, and (iii) the world wide promotional aspect. To solve these problems, the Helios project has chosen to integrate its public documentation and software material into a hypertext system using the World Wide Web.

Computer Communication Networks↗