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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.

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At least 433 records · Page 24Linked to original sources
PubMed1996

[A proposal for dosage and volume specification and documentation in HDR brachytherapy].

BACKGROUND: Modern computer-aided brachytherapy techniques and the various clinical and radiobiological methods require a review and standardization of dose specification and documentation in brachytherapy. METHOD: The methods and the extent of the dose specification and documentation have been analysed on the base of known international and national procedure. A new modified report has been prepared for the standardized dose specification for HDR-brachytherapy techniques. RESULT: Brachytherapy treatments are supposed to be documented in 3 different levels (I to III), the extent of which depending on the treated volume, the therapeutic aim and the equipment available. CONCLUSION: The extent of documentation and dose specification proposed in this paper requires the close cooperation of radio-oncologists and medical physicists. It seems to be advantageous to use prepared sheets or computer prints in order to minimize the time and efforts for a sufficient documentation.

Brachytherapy↗
PubMed1997

[Effects of the Health Structure Regulation on the form of documentation in clinics].

The requirements of the German Health Structure Law (GSG) are not matchable without the help of electronic data processing, especially regarding medical documentation in combination with the documentation for financial and calculation reasons. As a wide number of different and partly parallel keys are used, the electronic documentation has to be integrated in the clinical routine. Data have to be documented where they arise, by whom they are produced and unproductive double-documentation have to be avoided by any means. Investments in electronic data processing have to take into consideration the direct benefit for the user. This is a key to motivation and rises the validity of data.

Delivery of Health Care↗
PubMed1998

Photographic documentation of acute radiation-induced side effects of the oral mucosa.

BACKGROUND: Radiotherapy in cancer of the head and neck induces cutaneous and mucosal reactions. These must be carefully assessed and documentated to control the accuracy of individual treatment, the overall toxicity of particular treatment schedules, the efficacy of prophylaxis and treatment and to determine the adequate therapy of treatment sequelae depending on the severity of the reactions. The accurate classification of lesions according to internationally accepted schedules (WHO/RTOG/CTC) is indispensable for the comparison of radiotherapy treatment results and efficacy of supportive care. METHODS: While the treatment of cancer depends on tumor stage and medical circumstances of the patient and is more or less standardized, prophylaxis and treatment of side-effects is highly variable. Discussing an optimized prophylaxis and therapy of oral mucositis, the problem of accurate classification and documentation emerged. The verbal description of mucosal lesions is open to many subjective interpretations. Photographic documentation seems a suitable method to optimize the grading of toxicity. RESULTS: A photographic survey of typical lesions for each grade of toxicity is a tool to reach several aims in one step. Toxicity of an individual patient may be compared with representative photographic examples in daily routine to decide quickly on the grade of toxicity. Subjective differences due to intra- and interpersonal variability of the evaluating radiooncologist will be reduced. The efficacy of treatment can be proven by accurate documentation. Randomized clinical studies concerning prophylaxis and treatment of oral mucositis will provide more reliable results if evaluation of toxicity grading is standardized by photographs. CONCLUSIONS: Photographic documentation of lesions of the oral mucosa might be the best means to reduce interindividual subjectivity in grading. It is a valuable appendix to standard classification systems and only concerns the visible signs of mucosal lesions. However, the exact grading of mucositis is only possible with additional clinical information about pain and nutritional situation.

Documentation↗
PubMed1998

HCFA documentation guidelines and the need for discrete data: a golden opportunity for applied health informatics.

BACKGROUND: The medical community is shocked by the complexity of the documentation now required to support the Medicare billing codes. This situation represents an opportunity for Electronic Medical Records that use discrete data to become a central factor at the point of care by fulfilling these stringent documentation specifications. METHODS: This empirical study explores whether a discrete data EMR has the ability to generate automatically a report describing what billing code is consistent with the documentation recorded. We tested this hypothesis on HBOC Pathways SMR by attempting to create algorithms that reflected the HCFA guidelines. We validated this process using historical records from the Cleveland Clinic. RESULTS: All the data elements required by HCFA were available as discrete data. Using algorithms, the billing code consistent with the documentation of the health care encounter could be automatically generated. CONCLUSIONS: EMRs using discrete data can substantially reduce the burden placed on health care providers by HCFA's new documentation guidelines. This benefit creates a window of opportunity for health informatics to become an integral tool in the provision of health care. Using EMRs for billing purposes can help achieve the loftier goal of using EMRs for quality improvement.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Tools to improve documentation of smoking status. Continuous quality improvement and electronic medical records.

BACKGROUND: Despite the deleterious effects of smoking on the nation's health and evidence that smoking cessation advice by family practice physicians is cost-effective, self-sustaining office systems to identify smokers in primary care clinics have been difficult to establish. We worked on a continuous quality improvement project group, aided by an electronic medical record, to design a system to document and periodically update smoking status in a consistent place in the medical record. INTERVENTION: Using the continuous quality improvement plan-do-study-act cycle, a 7-member group worked with nursing staff to define roles, routines and responsibilities for medical assistants to screen for and document 1 of 4 categories of smoking status in the major problem list of the electronic medical record for at least 80% of patient appointments. Screening rate was tracked monthly by means of the electronic medical record and feedback was given to staff. RESULTS: The screening rate rose from 18.4% to 80.3% within 2 weeks after the system was implemented and was maintained for 19 months. An additional benefit was an increased rate of smoking cessation counseling documented by providers, from a baseline rate of 17.1% to 48.3%. CONCLUSIONS: A continuous quality improvement group process aided by an electronic medical record is useful to develop a self-sustaining office system to screen, document, and periodically update smoking status in a consistent place in the medical record. Although screening for and documenting smoking status are only the first step toward helping patients stop smoking, it is an important one.

Family Practice↗
PubMed1999

The tobacco industry and underage youth smoking: tobacco industry documents from the Minnesota litigation.

OBJECTIVE: To learn how underage youth have been regarded by the major tobacco companies, as revealed in industry documents during the Minnesota litigation. DATA SOURCES: Documents from Brown & Williamson Tobacco Corp, Lorillard Tobacco Co, Philip Morris Inc, and R. J. Reynolds Tobacco Co. STUDY SELECTION: Documents available from the State of Minnesota and Blue Cross and Blue Shield of Minnesota v Philip Morris Inc et al during the discovery process of the trial. Hundreds of industry documents related to youth, teenagers, and young adults were examined. A sample of documents are referenced as illustrations of key points. CONCLUSIONS: Underage youths are viewed by the tobacco industry as critical to its future. Underage youth smoking patterns were examined for decades. Reductions in youth smoking rates were seen by tobacco companies as a negative trend for the companies. Specific marketing campaigns were directed at underage youth and were successful with this age group. Tobacco industry practices should continue to be carefully scrutinized.

Adolescent↗
PubMedDate not supplied

Chemical and physical analysis for the improvement of the dry mounting method for fragile documents.

Paper lamination is a widely used method to consolidate fragile documents. Previous studies have presented a new method of lamination that allows the consolidation of documents before undertaking aqueous treatments. In this method a thin Japanese paper coated with an acrylic resin is applied on the fragile document by means of a heated press. In this work we optimised the preparation of the lamination sheets as well as the working procedures, and we were able to establish that our laboratory-made specimens are chemically stable, easily reversible and permeable to aqueous solutions. The latest property is of particular importance, since it allows a subsequent aqueous deacidification even for fragile documents. The laminated paper documents were further analysed by means of colorimetry and FTIR spectroscopy before and after accelerated ageing as well as by determination of the alkali reserve left on the coated paper, in order to compare our lamination method with other commercially available lamination sheets.

Acrylic Resins↗
PubMed2002

Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery.

OBJECTIVE: Nowadays, registration of patient data on paper is gradually being replaced by registration using an intensive care information system (ICIS). The aim of this study was to evaluate the effect of the use of an ICIS on nursing activity. DESIGN: Randomized controlled trial with a crossover design. SETTING: An 18-bed medical-surgical ICU in a teaching hospital. PATIENTS, NURSES AND INTERVENTIONS: During a 6week period 145 consecutive adult patients admitted to the ICU after uncomplicated cardiothoracic surgery were randomized into two groups: for one group the documentation was carried out using a paper-based registration (Paper), in the second group an ICIS was used for documentation. MEASUREMENTS AND RESULTS: The nursing activities for these patients were studied during two separate periods: the admission period and the registration phase (the period directly following the admission procedure). The duration of the admission procedure was measured by time-motion analysis and the nursing activities in the registration phase were studied by work sampling methodology. All nursing activities during the registration phase were grouped in four main categories: patient care, documentation, unit-related and personal time. The duration of the admission procedure was longer in the ICIS group (18.1+/-4.1 versus 16.8+/-3.1 min, p<0.05). In the registration phase, a 30% reduction in documentation time (Paper 20.5% of total nursing time versus ICIS 14.4%, p<0.001), corresponding to 29 min (per 8h nursing shift) was achieved. This time was completely re-allocated to patient care. CONCLUSIONS: The use of the present ICIS in patients after cardiothoracic surgery alters nursing activity; it reduces the time for documentation and increases the time devoted to patient care. ELECTRONIC SUPPLEMENTARY MATERIAL: is available if you access this article at http://dx.org/10.1007/s00134-002-1542-9. On that page (frame on the left side), a link takes you directly to the supplementary material.

Adult↗
PubMed2006

A point of care clinical documentation system for hospice care providers.

This article identifies two areas of hospice care that may benefit the most from a point-of-care (POC) clinical documentation system: documentation for recertification and symptom/pain management. Applications as solutions for the hospice POC clinical documentation system need two documentation support tools: (1) knowledge-based external or internal reference data available to physicians or medical staff right at the bedside and (2) assisting medical staff in filling out electronic forms for clinical measurements by providing real-time prompts, clues, alerts, or other types of feedback, along with the common features such as pre-defined values in specific fields. Our study may encourage more software vendors to include clinical documentation support tools in their solutions.

Hospice Care↗
PubMed1992

Evaluation of a Meta-1-based automatic indexing method for medical documents.

This paper describes MetaIndex, an automatic indexing program that creates symbolic representations of documents for the purpose of document retrieval. MetaIndex uses a simple transition network parser to recognize a language that is derived from the set of main concepts in the Unified Medical Language System Metathesaurus (Meta-1). MetaIndex uses a hierarchy of medical concepts, also derived from Meta-1, to represent the content of documents. The goal of this approach is to improve document retrieval performance by better representation of documents. An evaluation method is described, and the performance of MetaIndex on the task of indexing the Slice of Life medical image collection is reported.

Abstracting and Indexing↗
PubMed2006

Identifying important concepts from medical documents.

Automated medical concept recognition is important for medical informatics such as medical document retrieval and text mining research. In this paper, we present a software tool called keyphrase identification program (KIP) for identifying topical concepts from medical documents. KIP combines two functions: noun phrase extraction and keyphrase identification. The former automatically extracts noun phrases from medical literature as keyphrase candidates. The latter assigns weights to extracted noun phrases for a medical document based on how important they are to that document and how domain specific they are in the medical domain. The experimental results show that our noun phrase extractor is effective in identifying noun phrases from medical documents, so is the keyphrase extractor in identifying important medical conceptual terms. They both performed better than the systems they were compared to.

Algorithms↗
PubMed2006

Discussing and documenting (do not attempt) resuscitation orders in a Dutch Hospital: a disappointing reality.

OBJECTIVE: To determine whether the introduction of a patient information sheet about do not attempt resuscitation (DNAR) orders and personal motivation of the medical staff results in an improvement in the documentation of the DNAR orders in the medical records. DESIGN: Retrospective chart review. METHOD: The medical records for all hospital admissions during February 2005 were checked for age, sex, admission time, admitting specialty, admission type (acute or planned), death, documentation of the DNAR order on the admission form, and if this order was complied with and under whose initiative the order was implemented or not. These data were compared to the medical records from 2 years earlier. RESULTS: In 2005, 119 (9.3%) medical records a DNAR order was found, compared to 10.7% in 2003. In the 43 patients who died DNAR orders were documented more often (18.6%) than in other patients (9%). The DNAR order was written more frequently for patients who were older (46.5 years versus 67.5 years), had a longer hospital admission period (4.2 versus 12.4 days) and for acute admissions. No difference was found for sex. Of the specialties with more than 10 admissions a month, the most frequently written DNAR orders came from internal medicine (36%) and pulmonology (31%); the least from cardiology (2.2%) and thoracic surgery (0%). In 9 of the 119 (7.6%) the DNAR orders were explained, most were initiated by the doctor (7), 1 by the patient an 1 by the family. CONCLUSION: Giving patients more information about DNAR orders and motivating medical staff personally does not influence the documentation of DNAR orders. If documented, it occurred more in the elderly and the deceased patients. Only a few DNAR orders were specified and most were initiated by the doctor.

Age Distribution↗
PubMed2002

Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas.

In the USA foreign-born women tend to have fewer low-birthweight births than US-born women from the same ethnicity. This "healthy migrant" effect could be caused by immigration of the fittest or by healthy people being deliberately selected in the immigration process. This study tests these hypotheses by comparing self-reported history of low-birth-weight among foreign-born documented and undocumented Latinas and US-born Latinas. The sample includes 2398 (57.5%) documented foreign-born Latinas, 782 (18.7%) undocumented foreign-born Latinas, and 993 (23.4%) US-born Latinas who initiated prenatal care at MIC-Women's Health Services/MHRA in New York City during 1996-1997. Only women who reported previous live births were included in the sample. Documented foreign-born Latinas were less likely than US-born Latinas to have low-birth-weight babies taking into account parity, age, risk, and education. There were no significant differences between rates of low-birthweight for undocumented foreign-born Latinas and US-born Latinas, or documented foreign-born Latinas. There was, however, a significant trend for rates of low-birthweight to increase from documented foreign-born to undocumented foreign-born to US-born women. This suggests that both official screening and migration of the fittest play a role in lower rates of low-birthweight among foreign-born Latinas compared to US-born Latinas.

Adult↗
PubMed1996

Slow pathway ablation in patients with documented but noninducible paroxysmal supraventricular tachycardia.

OBJECTIVES: The purpose of this study was to assess the clinical efficacy of radiofrequency ablation of the slow pathway in patients with documented but noninducible paroxysmal supraventricular tachycardia (PSVT) who have evidence of dual atrioventricular (AV) node pathways. BACKGROUND: Patients with a documented history of PSVT at times do not have inducible PSVT in the electrophysiology laboratory. Because dual AV node pathways serve as the substrate for AV node reentrant tachycardia (AVNRT), ablation of the slow pathway potentially may be useful in these patients. METHODS: The subjects in this prospective study were seven consecutive patients who underwent an electrophysiologic procedure because of documented PSVT and were found to have dual AV node physiology or inducible single AV node echo beats, but no inducible PSVT despite the administration of isoproterenol and atropine. Their mean (+/- SD) age was 33 +/- 13 years, and they had been symptomatic for 12 +/- 12 years. The frequency of the episodes of PSVT ranged from > or = 1/day to 1/month. The rate of the documented episodes ranged from 170 to 260 beats/min, and discrete P waves were not apparent. Slow pathway ablation was performed with 9 +/- 4 applications of radiofrequency energy using a combined anatomic and electrogram mapping approach. RESULTS: All evidence of dual AV node pathways was eliminated in six patients, and dual AV node physiology remained present in one patient. During a mean follow-up period of 15 +/- 10 months (range 8 to 27), no patient had a recurrence of symptomatic tachycardia (success rate 95% confidence interval 65% to 100%). CONCLUSIONS: Slow pathway ablation may be clinically useful in patients with documented but noinducible PSVT who have evidence of dual AV node pathways.

Adult↗
PubMedDate not supplied

Documentation and effective patient care planning.

The creation of effective home care documentation serves many important purposes. From a payor perspective, such as Medicare, the clinical documentation can provide the basis for covered care. On the other hand, poor documentation can raise questions about medical necessity and even eligibility criteria, such as the patient's homebound status. Documentation can either support payment for covered services or begin the cycle toward increased requests for information and more-focused medical review processes. The following discussion provides key tips, information, a comprehensive checklist, and outcomes examples that support the creation of "best practices" for home care organizations related to clinical documentation.

Community Health Nursing↗
PubMed2003

Step-by-step mark-up of medical guideline documents.

Approaches to formalization of medical guidelines can be divided into model-centric and document-centric. While model-centric approaches dominate in the development of clinical decision support applications, document-centric, mark-up-based formalization is suitable for application tasks requiring the 'literal' content of the document to be transferred into the formal model. Examples of such tasks are logical verification of the document or compliance analysis of health records. The quality and efficiency of document-centric formalization can be improved using a decomposition of the whole process into several explicit steps. We present a methodology and software tool supporting the step-by-step formalization process. The knowledge elements can be marked up in the source text, refined to a tree structure with increasing level of detail, rearranged into an XML knowledge base, and, finally, exported into the operational representation. User-definable transformation rules enable to automate a large part of the process. The approach is being tested in the domain of cardiology. For parts of the WHO/ISH Guidelines for Hypertension, the process has been carried out through all the stages, to the form of executable application, generated automatically from the XML knowledge base.

Artificial Intelligence↗
PubMed1999

Diagnosing brain death: the importance of documenting clinical test results.

Eighty-three cases of brain stem death referred to the South Thames Transplant Co-ordination Service were audited to determine the quality of brain stem death test records. Documentation of brain stem death tests were complete in only 41 (44%) cases at the time of referral. There was no significant difference in completeness, whether documentation was in patient's notes or on a designated checklist (p = 0.14). There were a greater number of omissions when the tests were documented in patient's notes rather than on a form (p = 0.01). There is a necessity to improve the quality of brain stem death test documentation in order to facilitate organ donation and safeguard the integrity of brain stem death testing. This requires a commitment by clinicians to improve the quality of documentation, which can be accomplished by recording all aspects of brain stem death tests, including the conclusion on a single designated checklist.

Brain Death↗
PubMed2000

Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.

This document was developed by a consensus conference initiated by Kristian Thygesen, MD, and Joseph S. Alpert, MD, after formal approval by Lars Rydén, MD, President of the European Society of Cardiology (ESC), and Arthur Garson, MD, President of the American College of Cardiology (ACC). All of the participants were selected for their expertise in the field they represented, with approximately one-half of the participants selected from each organization. Participants were instructed to review the scientific evidence in their area of expertise and to attend the consensus conference with prepared remarks. The first draft of the document was prepared during the consensus conference itself. Sources of funding appear in Appendix A. The recommendations made in this document represent the attitudes and opinions of the participants at the time of the conference, and these recommendations were revised subsequently. The conclusions reached will undoubtedly need to be revised as new scientific evidence becomes available. This document has been reviewed by members of the ESC Committee for Scientific and Clinical Initiatives and by members of the Board of the ESC who approved the document on April 15, 2000.*

Biomarkers↗