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At least 487 records · Page 27Linked to original sources
PubMed2002

Are quantitative methods sufficient to show why wards react differently to computer-based nursing documentation?

Computer-based documentation of the nursing process is being introduced into hospitals more and more. Frequently, the introduction is followed by an evaluation of positive and negative effects. However, the often-used quantitative evaluation methods cannot fully illuminate the different success factors of computer-based nursing documentation systems. We introduced a computer-based nursing documentation system on four wards of the University Medical Centre of Heidelberg and systematically evaluated its effects in a two-year study. The quantitative analysis of the results showed that the wards reacted differently to the documentation system. In this paper, we will first take a look at the quantitative results of our evaluation study, and will then discuss possible reasons for the detected differences. We will then argue that only qualitative methods can help to fully reveal both expected and unexpected reasons for differences between the wards. Analysing the reasons for the different reactions will help lead to a better understanding of the factors that lead influence the successful introduction of a computer-based nursing documentation system. Both quantitative analysis and qualitative analysis have a role in this information system evaluation.

Academic Medical Centers↗
PubMed2005

The American Psychiatric Association's resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians.

The psychiatric evaluation of a physician's fitness for duty is an undertaking that is both important to patients' well-being and to the physician-subject of the evaluation. It is necessary that psychiatrists who agree to perform such evaluations proceed in a careful and thorough manner. This document was developed to provide general guidance to the psychiatric evaluators in these situations. It was prepared by the American Psychiatric Association (APA) Council on Psychiatry and Law and Corresponding Committee on Physician Health, Illness, and Impairment, of which the authors are members. The Resource Document was approved by the APA Joint Reference Committee in June 2004. APA Resource Documents do not represent official policy of the American Psychiatric Association. This Resource Document was edited to conform to Journal style and has therefore been modified slightly from the original document approved by the APA.

Disability Evaluation↗
PubMedDate not supplied

[Records and documentation system. Its location within a program of alimentary, nutritional and metabolic intervention].

OBJECTIVES: To present the Records and Documentation System of the Metabolic, Nutrient and Feeding Intervention Program (PRINUMA), as conducted by the Nutritional Support Group (GAN) of the "Hermanos Ameijeiras" Hospital (Havana City, Cuba). BACKGROUND: Every action conducted upon the patient must have a document backup. Likewise, this action should be exhaustively described in a Standerdized Operating Procedure (SPO). The Records and Documentation System must provide with: (1) Primmary records for registering the actions conducted upon the patients, (2) SOP manuals gathering the actions prescribed in the PRINUMA for the recognition, treatment and prevention of hospital malnutrition (HM), and (3) Computerized clinical registries for storing, manipulation and dissemination of data collected by the GAN during its local operation. METHODS: The ISO 9001-9003 standard was adopted for describing the actions prescribed by the PRINUMA into the corresponding SOPs. Access 7.0 for Windows (Microsoft, USA) was used for the programming and operation of the GAN'S computerized Clinical Registry. Three phases were defined for the implementation of this System: I: start-up (minimal); II: extended; III: total (global). RESULTS: System implementation is in phase II. A Procedure Manual has been written with clinical, anthropometric, dietetic, dietotherapeutical and analytical actions prescribed by the PRINUMA for the treatment of HM. There is a second Manual reuniting the actions fostered by the PRINUMA's Quality Control & Assurance and the Records & Documentations Systems. GAN also has a Nutritional Clinical History and a computerized Clinical Registryt serving as digital counterpart of the former. The Registry stores data of varying type collected from over 1.800 patients attended in the 8 years of the GAN existence. CONCLUSIONS: The implementation of the PRINUMA's Records and Documentation System has allowed the elaboration of judgements about the utility and safety of the intervention measures installed in the institution by the GAN. Likewise, the System has supported the research activity of the Group, and has been particularly useful in the conduction of continuous education activities within the institution.

Cuba↗
PubMed2005

Documenting junctional ectopic tachycardia following pediatric open heart surgery.

OBJECTIVE: To determine appropriated documentations for diagnosis junctional ectopic tachycardia (JET) before treatment in post-operative open heart surgery and identify risk factors for post-operative cardiac arrhythmias in children. MATERIAL AND METHOD: The authors performed a retrospective chart review in 277 patients who underwent surgical corrections at British Columbia's Children Hospital from January 1st, 2000 to December 31st, 2001. History, clinical symptoms, complication of surgery and post-operative cardiac arrhythmias were reviewed from medical records. The authors investigated whether JET was being diagnosed accurately and whether it was being adequately documented prior to the initiation of therapy. The authors also identified risk factors that were associated with JET. All documentations before treatment were reviewed by Pediatric cardiologists to confirm diagnosis. RESULTS: Although the diagnostic accuracy (84%), sensitivity (87%), and specificity (84%) are high, a significant number of patients with post-operative arrhythmias were treated without adequate documentation of the arrhythmia. The documentation of arrhythmias in the Intensive Care Unit was largely limited to rhythm strips, with very few 12-lead ECGs and wire studies performed to assist with the diagnosis. CONCLUSION: The presented data indicates that, in this critically-ill population, there was an unacceptable number of patients with post-operative arrhythmias who may have been treated inappropriately. It is very important to emphasize the interpretation of wire studies, an investigation normally done in a critical care setting and whose interpretation is very important to the accurate diagnosis of pediatric arrhythmias.

Adolescent↗
PubMed2006

Theoretical considerations of ethics in text mining of nursing documents.

This paper discusses theoretical considerations of ethics in building and using a text mining application in nursing documentation. Nursing documentation is based on the process of gathering information from the patient, setting goals for care, documenting nursing interventions and evaluating delivered nursing care. Privacy-sensitive health care documentation brings specific ethical concerns and difficulties that one needs to be aware of and conform to when developing and using text mining tools in electronic patient records. We discuss how patient confidentiality can be ensured in this domain and how text mining might support nurses to give better and more efficient care for their patients. Our conclusion is that text mining of nursing documents holds the promise of great benefits when the potential risks are taken into consideration.

Confidentiality↗
PubMed1991

An 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↗
PubMed1991

Documentation in critical care: a flow sheet format that communicates and saves time.

The design of a critical care nursing documentation form in a flow sheet format provides quick access to and rapid communication about patient information. Assessment parameters can be organized on the form to communicate standards of care, facilitate the nursing process, and save nursing time. The structure of a flow sheet format results in standardized documentation that simplifies quality assurance review and eliminates duplicate documentation. Nursing staff members comment on how easy charting is when the standards for documentation are clear. Staff members no longer waste time charting; they save time communicating. Our goals to effectively and accurately communicate the patient's status and to document nursing care efficiently and accurately have been achieved.

Communication↗
PubMed1988

Documentation and appropriateness of prescribing for Veterans Administration ambulatory-care patients.

Information about active prescriptions in pharmacy medication profiles of outpatients at a Veterans Administration (VA) medical center was compared with corresponding information in the medical records to determine the completeness of prescription documentation. Appropriateness of prescribing was assessed by comparison with explicit criteria. Information about the active prescriptions included in 300 randomly selected patient medication profiles was collected from August to October 1984. The completeness of prescription information documentation was determined by comparing the data obtained from the patient's medication profile with the corresponding medical record entry. Medication profiles were screened for three types of potentially inappropriate prescribing: inappropriate daily dosage, inappropriate duplication of therapy, and interacting drug combinations. A total of 287 patient medication profiles and medical records were studied. Only 60 medical records (20.9%) had accurate documentation of all drug names, drug strengths, and directions for use when compared with the medication profiles. Evidence of potentially inappropriate prescribing was present in medication profiles of 43.4% of the patients. Medical record documentation was insufficient for a provider to detect 50.0% of the dosage deviations, 33.3% of the duplications of therapy, and 26.1% of the drug-drug interactions. The probability that evidence of potentially inappropriate prescribing would be present in a medication profile increased as the number of drugs per patient increased. However, there was no significant positive association between insufficient medical-record documentation and the presence of any of the three indicators of potentially inappropriate prescribing in the medication profile.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗
PubMed1982

[Computerized documentation of the topicality of pain].

The exact and objective classification and documentation of pain is a difficult problem which is not easy to overcome. Therefore it seems necessary to reduce as for as possible all mistakes resulting from misunderstandings between pain information given by the patient and documentation carried out by the physician. Therefore a system should contribute to simplify the documentation of pain localisation. By means of dividing the human body into regions and numbering the pain-areas even computer documentation becomes feasible. Thus the standardization of pain area documentation permits its application as parameter in research projects with a large number of cases.

Computers↗
PubMed1995

Looking through a keyhole at the tobacco industry. The Brown and Williamson documents.

OBJECTIVE: To introduce a series of papers discussing previously undocumented tobacco industry activities regarding strategies to avoid products liability litigation, understand nicotine addiction, and manipulate both internal and external scientific research on the effects of both active and passive smoking. DATA SOURCES: Documents from Brown and Williamson Tobacco Corporation (B&W), the British American Tobacco Company (BAT), and other tobacco interests provided by an anonymous source, obtained from Congress, and received from the private papers of a former BAT officer. STUDY SELECTION: All available materials, including confidential reports regarding research and internal memoranda exchanged between tobacco industry lawyers. CONCLUSIONS: These documents provide our first look at the inner workings of the tobacco industry during the crucial period in which the scientific case that smoking is addictive and kills smokers solidified. The documents show a sophisticated legal and public relations strategy to avoid liability for the diseases induced by tobacco use. The documents show that lawyers steered scientists away from particular research avenues, which is inconsistent with the company's purported disbelief in the causation and addiction claims; if the company had been genuinely unconvinced by the causation and addiction hypotheses, then it should have had no concern that new research would provide ammunition for the enemy. Quite the contrary, the documents show that B&W and BAT recognized more than 30 years ago that nicotine is addictive and that tobacco smoke is "biologically active" (eg, carcinogenic).

Humans↗
PubMed1995

Lawyer control of internal scientific research to protect against products liability lawsuits. The Brown and Williamson documents.

OBJECTIVE: To understand how attorneys for the tobacco industry in general, and Brown and Williamson Tobacco Corporation (B&W) in particular, have responded to the threat of products liability litigation arising from smoking-induced diseases. DATA SOURCES: Documents from B&W, the British American Tobacco Company (BAT), and other tobacco interests provided by an anonymous source, obtained from Congress, or received from the private papers of a former BAT officer. STUDY SELECTION: All available materials, including confidential reports regarding research and internal memoranda exchanged between tobacco industry lawyers. CONCLUSIONS: The documents demonstrate that the tobacco industry in general, and B&W in particular, were very concerned about the threat of products liability lawsuits, and they illustrate some of the steps taken by lawyers at one company to avoid the discovery of documents that might be useful to a plaintiff in such a lawsuit. These steps included efforts to control the language of scientific discourse on issues related to smoking and health, to bring all potentially damaging internal scientific documents under attorney work product and attorney-client privilege to avoid discovery, to remove "deadwood" documents, and to insulate B&W from knowledge of potentially damaging scientific information from other BAT companies.

Consumer Product Safety↗
PubMed1993

Intelligent processing of loosely structured documents as a strategy for organizing electronic health care records.

Loosely structured documents can capture more relevant information about medical events than is possible using today's popular databases. In order to realize the full potential of this increased information content, techniques will be required that go beyond the static mapping of stored data into a single, rigid data model. Through intelligent processing, loosely structured documents can become a rich source of detailed data about actual events that can support the wide variety of applications needed to run a health-care organization, document medical care or conduct research. Abstraction and indirection are the means by which dynamic data models and intelligent processing are introduced into database systems. A system designed around loosely structured documents can evolve gracefully while preserving the integrity of the stored data. The ability to identify and locate the information contained within documents offers new opportunities to exchange data that can replace more rigid standards of data interchange.

Database Management Systems↗
PubMedDate not supplied

Accuracy of patient recall and chart documentation of falls.

BACKGROUND: This 1-year prospective study examined the accuracy of patient recall of falls and fall injuries and completeness of chart documentation of these events. METHODS: One hundred ambulatory geriatric family practice patients reported falls weekly by postcard with telephone call follow-up. On a final postcard they reported their recall of falls and fall injuries in the preceding 3-, 6-, and 12-month periods. Patient charts were reviewed for fall documentation. RESULTS: For the 3-, 6-, and 12-month periods, respectively, 31 percent, 44 percent, and 89 percent of participants who had reported a fall recalled at least one fall. Sixty-eight percent of participants who had reported an injury recalled one at the year's end. The positive predictive value of recalling a fall was 92 percent and of recalling a fall injury was 72 percent for the 1-year period. Only 10 of 56 (18 percent) reported falls were documented in the patient's chart. CONCLUSIONS: Patients recalled falls and injuries in the previous 12 months well, but they were less accurate for recall periods of 3 and 6 months. Few reported falls were documented by the patient's physician. Awareness of falls can be increased by asking the patient about falls during the previous year and by documenting all reported and recalled falls.

Accidental Falls↗
PubMedDate not supplied

The impact of computerized documentation on nurses' use of time.

With increased consideration being given to technological supports as a way to increase productivity, much attention is being paid to automated documentation systems. The purpose of this study was to determine (A) if bedside documentation technology decreased the time nurses spent in documentation activities and (B) if time of day, location, and quality of documentation differed between automated and nonautomated units. Nurses on the automated unit were able to decrease time spent in documentation activities and they were able to increase time spent in direct patient care. Some increase in standby time also was reported. Nurses were not able to increase patient loads as a result of this technology alone. Managers must consider ways to maximize use of time saved as a result of technology. Nurses on the automated unit were able to update care plans more easily and, along with other professionals, reported both positive and negative aspects of the printed output.

Efficiency, Organizational↗
PubMed1997

The clinic-specific thesaurus: a means of "lean documentation" in pediatric surgery.

A one-hundred percent documentation rate of diagnoses and patient data is unfeasible and should not be pursued. Therefore, a "lean documentation" of diagnoses and basic patient data was introduced. Coding is done by a clinic-specific list of diagnoses (thesaurus) with a minimum of diagnostic codes, combined with optional free text. By recording the frequency of diagnoses for two years, a thesaurus of 188 diagnostic codes was developed. Bedside coding by treating physicians reduced medical and semantic mistakes of documentation. Cooperation of the clinicians was obtained by shortening the time required for coding to less than two minutes per patient. A documentation assistant supplemented incomplete data in collaboration with the treating surgeons. During a ten-year testing period 93.7% of the hospital-specific codes of our thesaurus were required for documentation, as compared to 13.1% if the same patients were coded by ICD-9. Consequently, coding by a clinic-specific code thesaurus is quick flexible and accurate.

Child↗
PubMedDate not supplied

Computerized documentation of case management. From diagnosis to outcomes.

Documentation of patient care, outcomes, and report writing are important aspects of the role of the case manager. In this article, the author examines the types of documentation approaches used by nurses in recent years and the new applications called for in the case manager role. Issues such as standardized language and multidisciplinary documentation are explored. Approaches to examining computerized documentation systems are presented. Finally, the importance of documentation in demonstrating what nurses do, allowing comparison of outcomes, and supporting reimbursement for nurses, are discussed.

Case Management↗
PubMedDate not supplied

Use of a structured encounter form to improve well-child care documentation.

OBJECTIVE: To determine if a structured encounter form for well-child care improves documentation of well-child care. DESIGN: Retrospective medical record review of a before-and-after trial. SETTING: Family practice residency clinic serving a primarily low-socioeconomic urban population. PATIENTS: Children younger than 6 years receiving well-child care visits. INTERVENTION: Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force. MAIN OUTCOME MEASURES: Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form. RESULTS: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form. CONCLUSIONS: The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.

Child↗
PubMed1990

But they are not thresholds: a critical analysis of the documentation of Threshold Limit Values.

Threshold Limit Values (TLVs) represent conditions under which the TLV Committee of the American Conference of Governmental Industrial Hygienists (ACGIH) believes that nearly all workers may be repeatedly exposed without adverse effect. A detailed research was made of the references in the 1976 Documentation to data on "industrial experience" and "experimental human studies." The references, sorted for those including both the incidence of adverse effects and the corresponding exposure, yielded 158 paired sets of data. Upon analysis it was found that, where the exposure was at or below the TLV, only a minority of studies showed no adverse effects (11 instances) and the remainder indicated that up to 100% of those exposed had been affected (8 instances of 100%). Although, the TLVs were poorly correlated with the incidence of adverse effects, a surprisingly strong correlation was found between the TLVs and the exposures reported in the corresponding studies cited in the Documentation. Upon repeating the search of references to human experience, at or below the TLVs, listed in the more recent, 1986 edition of the Documentation, a very similar picture has emerged from the 72 sets of clear data which were found. Again, only a minority of studies showed no adverse effects and TLVs were poorly correlated with the incidence of adverse effect and well correlated with the measured exposure. Finally, a careful analysis revealed that authors' conclusions in the references (cited in the 1976 Documentation) regarding exposure-response relationships at or below the TLVs were generally found to be at odds with the conclusions of the TLV Committee. These findings suggest that those TLVs which are justified on the basis of "industrial experience" are not based purely upon health considerations. Rather, those TLVs appear to reflect the levels of exposure which were perceived at the time to be achievable in industry. Thus, ACGIH TLVs may represent guides of levels which have been achieved, but they are certainly not thresholds.

Air Pollutants, Occupational↗