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At least 451 records · Page 25Linked to original sources
PubMed2000

[Electronic documentation in medicine; flexible concepts versus isolated solutions].

Computer-based medical documentation so far proved advantageous especially through standardization of data entry and increased access speed. Additional benefits can be achieved through the implementation of integrated, cross-project documentation tools and their integration into the clinical work-flow, which allow data to be used for a wide variety of applications (e.g. quality management, clinical research, clinic management). The presence of incompatible documentation software often complicates the realization of these goals. Implementation of new documentation tools therefore should consider flexibility and multiple-use of data as primary design goals. In the presented paper requirements for flexible documentation tools are introduced. The Entity-Attribute-Value-Model is described as a possible means of implementation. Practical experiences made with a prototype application are reported.

Germany↗
PubMed2002

The prevalence and documentation of impaired mental status in elderly emergency department patients.

STUDY OBJECTIVE: We sought to determine the prevalence of mental status impairment in elderly emergency department patients and to assess documentation of and referrals by emergency physicians for mental status impairment after discharge from the ED. METHODS: We performed a prospective, observational study of a convenience sample of 297 patients 70 years or older presenting to an urban teaching hospital ED over a 12-month period. Patients were screened with the Orientation-Memory-Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Documentation, dispositions, and referrals were abstracted from chart review. RESULTS: Two hundred ninety-seven of the 337 eligible patients were enrolled. Seventy-eight of the 297 (26%; 95% confidence interval [CI] 21% to 31%) patients had mental status impairment; 30 (10%; 95% CI 7% to 14%) had delirium; 48 (16%; 95% CI 12% to 20%) had cognitive impairment without delirium; 17 (6%; 95% CI 3% to 9%) screened positive on both examinations. Only 22 (28%; 95% CI 19% to 40%) of the 78 patients had any documentation of mental status impairment by the emergency physician. Specific mention of delirium, cognitive impairment, or an acceptable synonym was noted in 13 (17%; 95% CI 9% to 27%). Of 34 (44%; 95% CI 32% to 55%) patients with mental status impairment discharged home, only 6 (18%; 95% CI 7% to 35%) had plans documented by the emergency physician to address impairment. Eleven (37%; 95% CI 20% to 56%) of the 30 patients with delirium were discharged home. Sixteen (70%; 95% CI 47% to 87%) of the 23 patients with cognitive impairment who were discharged home had no prior history of dementia; these patients were less likely to have specialized assistance with care (13%; 95% CI 4% to 27%) than those with known dementia (58%; 95% CI 28% to 85%). CONCLUSION: Impaired mental status is common among older ED patients. Lack of documentation, admission, or referral by emergency physicians suggests a lack of recognition of this important problem.

Aged↗
PubMed2005

Taking it to the streets: responses of African American young adults to internal tobacco industry documents.

Since the Master Settlement Agreement of 1998 between 46 states and the major tobacco companies forced the release of over 30 million pages of previously secret internal tobacco industry documents, researchers have been exploring how information in the documents can be useful for advancing public health efforts. Previous research shows that the tobacco industry has made massive efforts to target marginalized communities, not only through typical advertising channels but also through establishing financial and other ties with influential leadership groups. However, no previous studies have explored how members of targeted groups might respond at the grassroots level to actual internal tobacco industry documents about such targeting. This exploratory focus group study, which invited urban African American participants to comment on previously secret internal tobacco industry documents, suggests that such documents may be useful in efforts to socially denormalize tobacco use, promote critical reflection about community targeting, and mobilize individuals toward quitting.

Adult↗
PubMed1997

Computerized documentation of activities of Pharm.D. clerkship students.

A method for documenting the contributions of entry-level Pharm.D. clerkship students at a teaching hospital is described. Between mid-September 1995 and April 1996, students were asked to use a cost-accounting software program to document time spent on various activities associated with inpatient pharmacy services. The system was already being used for documenting the clinical activities of staff pharmacists; pharmacists entered activities in the same way that they entered medication orders, using a mnemonic for a clinical activity in place of a drug name and time spent on the activity in place of a dosage. Pharmacist preceptors verified the students' entries. Eleven students reported 3,466 clinical events. Thirty-five pharmacists reported 54,299 clinical events during the same period. Students were responsible for 42.5% of the initial patient work-ups reported, 34.0% of the patient information and education episodes, and 24.6% of the inservice programs for physicians. On the basis of documented student contributions to the clinical workload, the pharmacy department requested additional clerkship students. The following year, 16 clerkship students were assigned to the department and the program was expanded to year-round clerkships. Pharmacy clerkship students contributed to the productivity data of a teaching hospital. Documentation of the students' contributions led to an expansion of the clerkship program.

California↗
PubMedDate not supplied

Alcohol drinking among emergency patients--alcometer use and documentation.

AIMS: To measure physicians' use of the alcometer (breath analysis test) and their documentation of alcohol-related findings among their patients. METHODS: Over one weekend, during which 100 adults attended the emergency clinic of a university hospital, data were collected on patients' alcohol consumption, physicians' use of an alcometer and alcohol-related documentation. Heavy drinkers were defined by the patient's response to a written questionnaire: Five-Shot total score >or=3 points, and/or >or=7 drinks per one occasion. RESULTS: The questionnaire was filled in by 96 patients; 26 (27%) were heavy drinkers. The alcometer was used in 7% of patients including 5 of 26 (19%) of the heavy drinkers. For only 12/26 (46%) heavy drinkers was there written information on alcohol use in the medical record. For 6 of the 20 patients whose visit was primarily considered by the physician to be alcohol-related, no documentation on alcohol appeared in the records. When documentation was present, drinking quantities were not usually recorded. CONCLUSIONS: It is a challenge to increase the emergency clinic staff's activity in detection and documenting alcohol abuse.

Adolescent↗
PubMed2006

Cardiopulmonary resuscitation: capacity, discussion and documentation.

BACKGROUND: End-of-life care decisions, including treatment such as cardiopulmonary resuscitation (CPR), are complex issues requiring a patient to have the capacity for effective decision-making. AIM: To assess the prevalence and documentation of CPR decisions in our hospital in patients aged > 65 years. DESIGN: Prospective audit. METHODS: Review of patient notes and resuscitation forms within our acute Trust on Elderly Care and General Medicine wards, including the decisions made, involvement of patient and/or family members and whether an assessment of capacity was made. RESULTS: On the Elderly Care wards, 37 CPR decisions were made on 104 patients, and nearly all of these were clearly documented. On the General Medical wards, only one decision out of 40 patients was made. Geriatricians incorporated patient views in one quarter of decisions; all but one of these patients wanted CPR. Of those patients 'not for CPR', family members were informed in only one third of cases, according to the documentation. Capacity was documented on only four occasions. DISCUSSION: Geriatricians make significantly more CPR decisions than general physicians do, but still involve patient and family views in only a minority of cases, and an assessment of capacity is rarely explicitly documented. We suggest a three-step approach to clinical decision making, to increase both the volume and the quality of CPR decisions, which may be improved further by the use of information leaflets for patients and their families.

Aged↗
PubMedDate not supplied

The times they are a changing: effects of online nursing documentation systems.

Safe patient care is at the front line when delivering patient care. Point-of-care online nursing documentation is presented as a possible solution. With the implementation of online nursing documentation, questions arise if this technology will improve the quality of nursing documentation as well as end user satisfaction. Five research articles are critiqued and it is concluded that overall online nursing documentation systems would be beneficial in improving documentation requirements and end user satisfaction and help influence how nursing is practiced.

Attitude of Health Personnel↗
PubMedDate not supplied

Tuberculosis cases in Wisconsin: documentation of treatment improvement and completion of treatment, 2000-2002.

OBJECTIVE: In 2000, the Wisconsin Strategic Plan for the Elimination of Tuberculosis (TB) sets goals of 90 percent treatment completion and 95 percent documentation of treatment improvement for all reported cases of TB. This study measures the success in achieving these goals. METHODS: Data were abstracted from charts of all 249 reported TB cases during 2000-2002. Treatment completion was considered for patients indicated for completion in 12 months or less. Documentation of treatment improvement included therapy adherence, sputum culture conversion, and chest radiograph improvement for pulmonary cases, and therapy adherence and clinical improvement for extrapulmonary cases. RESULTS: Treatment completion was measured in 204 of 249 TB cases; 87.1 percent completed treatment in 12 months or less. There was a significant difference in completion by site of disease, 89.9 percent for pulmonary cases and 66.1 percent for extrapulmonary cases (P < .01). Documentation of treatment improvement was 61.2 percent among pulmonary cases and 83.6 percent among extrapulmonary cases (P < .01). During the study period, there was a significant decrease in documentation rates for patients with pulmonary TB (P < .01). CONCLUSIONS: The goal of 90 percent treatment completion was nearly accomplished but the goal of 95 percent documentation of treatment improvement was not achieved. Barriers to TB treatment in Wisconsin need to be identified. Case management of TB is necessary for control and prevention of TB.

Adolescent↗
PubMed1987

A new dimension in documentation: the PIE method.

In February 1986, the 43-bed neurology/neurosurgery unit at a midwestern medical center implemented the problem identification, intervention, and evaluation (PIE) method of documentation. This method incorporates the plan of care into the nursing progress notes, eliminating the need for a traditional care plan. Identified patient problems are documented on a problem list in the form of nursing diagnoses. These problems are evaluated each shift in the nursing progress notes. Routine interventions and assessments are documented on a comprehensive flow sheet. Since the inception of the PIE method, the quality of documentation on the unit has increased, while time spent on charting has decreased. Professional accountability and credibility are evident as nurses document nursing interventions and evaluate their effectiveness.

Adult↗
PubMed2001

Increased patient concern after false-positive mammograms: clinician documentation and subsequent ambulatory visits.

OBJECTIVE: To measure how often a breast-related concern was documented in medical records after screening mammography according to the mammogram result (normal, or true-negative vs false-positive) and to measure changes in health care utilization in the year after the mammogram. DESIGN: Cohort study. SETTING: Large health maintenance organization in New England. PATIENTS: Group of 496 women with false-positive screening mammograms and a comparison group of 496 women with normal screening mammograms, matched for location and year of mammogram. MEASUREMENTS AND MAIN RESULTS: 1) Documentation in clinicians' notes of patient concern about the breast and 2) ambulatory health care utilization, both breast-related and non-breast-related, in the year after the mammogram. Fifty (10%) of 496 women with false-positive mammograms had documentation of breast-related concern during the 12 months after the mammogram, compared to 1 (0.2%) woman with a normal mammogram (P =.001). Documented concern increased with the intensity of recommended follow-up (P =.009). Subsequent ambulatory visits, not related to the screening mammogram, increased in the year after the mammogram among women with false-positive mammograms, both in terms of breast-related visits (incidence ratio, 3.07; 95% confidence interval [CI], 1.69 to 5.93) and non-breast-related visits (incidence ratio, 1.14; 95% CI, 1.03 to 1.25). CONCLUSIONS: Clinicians document concern about breast cancer in 10% of women who have false-positive mammograms, and subsequent use of health care services are increased among women with false-positive mammogram results.

Adult↗
PubMed1997

Accuracy of patient care staff in estimating and documenting meal intake of nursing home residents.

OBJECTIVES: To determine the accuracy of patient care staff estimates and documentation of food intake of residents in nursing homes. DESIGN: Prospective, observed, unblinded cohort study. SETTING: Three urban nursing home facilities. SUBJECTS: Staff estimation and documentation of 27 nursing home residents' meal intake. MEASUREMENTS: Actual amount consumed by 27 nursing home residents was ascertained by weighing food and caloric fluids on resident trays before and after one lunch time meal. Staff estimates and documentation of percent of meal consumed was compared with actual intake. RESULTS: Patient care staff estimates differed from actual intake by approximately 20%, and in most instances intake was overestimated. Almost one-third of the residents at risk for nutritional problems were not identified correctly by staff. Chart documentation of meal intake frequently did not reflect either actual amount of meal consumed or the staff's estimation of what was eaten. CONCLUSION: Study findings indicate that the present system used to document nursing home residents' intake is inadequate and that a more accurate mechanism or an entirely different process for identifying residents at risk for nutritional problems should be developed and implemented.

Aged↗
PubMed1994

The value of electrophysiologic testing in patients resuscitated from documented ventricular fibrillation.

INTRODUCTION: Electrophysiologic testing is performed in patients resuscitated from ventricular fibrillation (VF) on the assumption that sustained monomorphic ventricular tachycardia (VT) may be a precursor to VF, with the former amenable to assessment by serial drug testing. METHODS AND RESULTS: We assessed the usefulness of this strategy by analyzing clinical and electrophysiologic data of 42 survivors (29 men and 13 women; mean age 54 +/- 14 years) of VF without a reversible cause. All patients had VF documented on ECG and required defibrillation. Underlying heart diseases included coronary disease in 28, dilated cardiomyopathy in 3, arrhythmogenic right ventricular dysplasia in 1, and no apparent structural heart disease in 10 patients. Only 2 (4.7%) patients had a prior history of documented VT. The electrophysiologic study was performed 7 to 30 days after VF. Programmed stimulation at the right ventricular apex using at least two drive cycle lengths and up to three extrastimuli induced sustained monomorphic VT in 4 (9.5%), sustained polymorphic VT in 3 (7.1%), nonsustained monomorphic VT in 1 (2.3%), nonsustained polymorphic VT in 5 (11.9%), and VF in 13 (30.9%) patients. Two patients with documented prior VT and coronary disease had sustained VT induced during the electrophysiologic study. On the other hand, sustained monomorphic VT was induced in 53 of the 59 (90%) patients (45 men and 14 women; mean age 57 +/- 16 years) with clinically documented VT concurrently studied using the same stimulation protocol. CONCLUSION: We conclude that reproducible induction of sustained monomorphic VT in survivors of documented VF is uncommon. It may be more cost effective to proceed directly to treatment with implantable cardioverter defibrillators in these patients.

Adult↗
PubMed2000

Documentation of care outcomes in an academic nursing clinic: an assessment.

PURPOSE: To assess documentation of client data collected at an academic nursing clinic using the Wilson and Cleary Health Related Quality of Life (HRQOL) conceptual model as a framework. DATA SOURCES: A chart audit of 100 randomly selected active client records was conducted. CONCLUSIONS: Although several significant HRQOL variables were documented, data regarding general health perception and quality of life were not present. The HRQOL conceptual model provided an appropriate structure for evaluating the documentation. Further effort must be made to include key HRQOL dimensions in the clinic's documentation system. IMPLICATIONS FOR PRACTICE: Documenting the quality of care provided in nursing clinics is essential in order for other professionals and the public to recognize nursing professionals as accountable and credible. This project formed the basis for a computerized outcomes-based client record system.

Academic Medical Centers↗
PubMed2006

Car manufacturers and global road safety: a word frequency analysis of road safety documents.

OBJECTIVE: The World Bank believes that the car manufacturers can make a valuable contribution to road safety in poor countries and has established the Global Road Safety Partnership (GRSP) for this purpose. However, some commentators are sceptical. The authors examined road safety policy documents to assess the extent of any bias. DESIGN: Word frequency analyses of road safety policy documents from the World Health Organization (WHO) and the GRSP. MAIN OUTCOME MEASURES: The relative occurrence of key road safety terms was quantified by calculating a word prevalence ratio with 95% confidence intervals. Terms for which there was a fourfold difference in prevalence between the documents were tabulated. RESULTS: Compared to WHO's World report on road traffic injury prevention, the GRSP road safety documents were substantially less likely to use the words speed, speed limits, child restraint, pedestrian, public transport, walking, and cycling, but substantially more likely to use the words school, campaign, driver training, and billboard. CONCLUSIONS: There are important differences in emphasis in road safety policy documents prepared by WHO and the GRSP. Vigilance is needed to ensure that the road safety interventions that the car industry supports are based on sound evidence of effectiveness.

Accidents, Traffic↗
PubMed1995

Documentation of blood culture results.

AIMS: To evaluate the adequacy of documentation of blood culture results in patients' medical notes. METHODS: A pro-forma was completed following review of medical notes at 24 and 48 hours after a blood culture had been reported as positive. The study was performed on blood cultures received at the Department of Microbiology, Royal Hallamshire Hospital, Sheffield, from two local hospitals. Two periods were studied: (A) May to June 1993 and (B) September to October 1993. RESULTS: There were 43 results studied in period A and 79 in period B, giving a total of 122 results studied. Overall, 72 (59%) of 122 results were recorded in the medical notes at 24 hours. Of those results deemed highly significant, 40 (63%) of 63 were recorded. There was no significant difference in the documentation of results if the result was given personally or via the telephone. Nor was there any difference in documentation between different medical grades. Throughout the study there were six inaccurate records. The cumulative documentation over 48 hours of positive results was 54 (86%) of 63 of highly significant, 27 (69%) of 39 of uncertain significance, and 11 (55%) of 20 probable contaminant results. CONCLUSIONS: Documentation of blood culture results is currently suboptimal.

Blood↗
PubMed2000

Soluble VCAM-1 and E-selectin, but not ICAM-1 discriminate endothelial injury in patients with documented coronary artery disease.

It has been shown that endothelial cell adhesion molecules play an important role in the development of coronary atherosclerosis and inflammatory disease. We sought to test whether soluble vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1) and E-selectin are increased in patients with documented coronary artery disease (CAD). Plasma levels of VCAM-1, ICAM-1 and E-selectin were measured in 40 patients with documented CAD, 20 subjects with angiographically documented normal coronary arteries, and 14 healthy volunteers. Patients with documented CAD exhibited significant elevation of VCAM-1 (535 +/- 227.1 ng/ml, p = 0.0001), E-selectin (69.4 +/- 29.4 ng/ml, p = 0.006), but not ICAM-1 (320.5 +/- 65.1 ng/ml, p = 0.9) concentrations as compared to subjects with normal coronary arteries (252.3 +/- 79.8, 49.7 +/- 22.0 and 311.4 +/- 40.2 ng/ml), and healthy controls (110.0 +/- 17.7, 29.0 +/- 2.0 and 237.5 +/- 46.5 ng/ml), respectively. Soluble markers of endothelial injury are not uniformly increased in patients with documented CAD as compared to those with normal coronary arteries and healthy controls. However, VCAM-1 and E-selectin, but not ICAM-1 could identify endothelial injury in such patients.

Adult↗
PubMed1996

Documented home apnea monitoring: effect on compliance, duration of monitoring, and validation of alarm reporting.

The objectives of this study were to: (1) measure patient compliance with monitoring, (2) validate parental reports of alarms at home, (3) examine monitoring duration, and (4) compare documented monitor records with the traditional pneumogram to evaluate patients for monitor discontinuation. During the 1-year period from January through December, 1992, 114 infants were followed up with documented monitoring. Simultaneously, 113 infants were followed up with conventional monitors. Infants were premature, or victims of apparent life-threatening episodes (ALTE), or siblings of SIDS victims. Monitors recorded all episodes of apnea greater than 15 seconds and bradycardia less than 80 beats per minute. All families were contacted biweekly by telephone. Downloads were performed at regular intervals. Monitor downloads were compared with simultaneous pneumograms to assess the accuracy of a long-term, intermittent event-recording system versus short-term (6- to 12-hour) continuous recording. All families were highly compliant with the use of home monitoring. Although Caucasian families used the monitors more often than non-Caucasian families, all groups used the monitor > 75% of the time. True episodes were verified in 38% of patients by monitor downloads. Only 7.4% of all recorded events were true events. Of the real events, 51.2% were apneas of 16-20 seconds. No significant differences were found in overall duration of monitoring between documented and nondocumented monitors. In the premature infants, the duration of monitoring was significantly reduced in those infants found to have no true episodes over those with real events at home. Readmission for ALTE was reduced in infants with documented monitors. Premature infants without events were monitored an average of 24 fewer days (P = 0.03). Computerized monitor downloads were found to be equally, if not more, sensitive than pneumograms in evaluating infants for monitor discontinuation. Documented monitoring offers a viable alternative to traditional monitoring and pneumograms in assisting clinicians and families in evaluating their infant's progress. By accurately assessing compliance, distinguishing true from false alarms, and decreasing the need for pneumograms, these devices provide valuable information to clinicians and families.

Apnea↗
PubMed2006

The TREC 2004 genomics track categorization task: classifying full text biomedical documents.

BACKGROUND: The TREC 2004 Genomics Track focused on applying information retrieval and text mining techniques to improve the use of genomic information in biomedicine. The Genomics Track consisted of two main tasks, ad hoc retrieval and document categorization. In this paper, we describe the categorization task, which focused on the classification of full-text documents, simulating the task of curators of the Mouse Genome Informatics (MGI) system and consisting of three subtasks. One subtask of the categorization task required the triage of articles likely to have experimental evidence warranting the assignment of GO terms, while the other two subtasks were concerned with the assignment of the three top-level GO categories to each paper containing evidence for these categories. RESULTS: The track had 33 participating groups. The mean and maximum utility measure for the triage subtask was 0.3303, with a top score of 0.6512. No system was able to substantially improve results over simply using the MeSH term Mice. Analysis of significant feature overlap between the training and test sets was found to be less than expected. Sample coverage of GO terms assigned to papers in the collection was very sparse. Determining papers containing GO term evidence will likely need to be treated as separate tasks for each concept represented in GO, and therefore require much denser sampling than was available in the data sets. The annotation subtask had a mean F-measure of 0.3824, with a top score of 0.5611. The mean F-measure for the annotation plus evidence codes subtask was 0.3676, with a top score of 0.4224. Gene name recognition was found to be of benefit for this task. CONCLUSION: Automated classification of documents for GO annotation is a challenging task, as was the automated extraction of GO code hierarchies and evidence codes. However, automating these tasks would provide substantial benefit to biomedical curation, and therefore work in this area must continue. Additional experience will allow comparison and further analysis about which algorithmic features are most useful in biomedical document classification, and better understanding of the task characteristics that make automated classification feasible and useful for biomedical document curation. The TREC Genomics Track will be continuing in 2005 focusing on a wider range of triage tasks and improving results from 2004.

Journal Article↗