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PubMed1979

[An expanded basic documentation of treatment and follow-up for operated cancer patients (author's transl)].

Presented is a program of recording all facts in the fate of a cancer patient relevant for therapy and prognosis in a manner suitable for EDP. Beside optimal medical treatment it is the substance of the documentation system to produce the complete pathogram of all registered cancer patients. From the day of establishment of the diagnosis and the begin of clinical treatment in the Evgl. Krankenhaus up to the following 5 years the cancer patient runs through a strongly termed and tumor specific follow-up. All informations and facts are registered in a codable medical record, a basic documentation for tumor patients, a follow-up and a final questionaire. In the so coded pathogram of the cancer patient we only use international binding classifications and coding systems. The pathogram is the result of a longer development and testing time in the surgical department of a smaller hospital. The presented principles of documentation include all basis necessary for the establishment of a clinical cancer registry and documentation follow-up.

Documentation↗
PubMed1996

Decisions to forego life-sustaining treatment and the duty of documentation.

OBJECTIVE: To study the current practice of documenting decisions to forego life-sustaining treatment in an intensive care unit (ICU), using the Swedish Medical Records Act as a frame of reference. SETTING: The ICU at Malmoe General Hospital, Sweden. MATERIALS: The medical records of the first 600 cases treated in the ICU in 1992. METHODS: Analysis of documents and informal observational procedures. RESULTS: Decisions to forego life-sustaining treatment were documented in the medical records of 34 patients, 17 of whom died in the ICU. In many cases, the treatment is specified, but often it is only rather vaguely described. The main reason for foregoing treatment is poor prognosis. There is no indication that the decisions had been discussed with the patients. In 18 of the 34 medical records, there are notes indicating that relatives were informed about the decision. Notes in most of the 34 medical records imply that joint deliberation took place between the anaesthesiologists in the ICU and the other physician(s) responsible for the treatment of the patient. CONCLUSION: The medical records give a fairly accurate picture of the frequency with which such decisions are made at this particular ICU, although the number might be somewhat underestimated. However, the content of the documentation is rather scanty and does not fully satisfy the requirements of the Swedish Medical Records Act. Further studies are needed to warrant any generalization.

Adolescent↗
PubMed1989

Multimedia document architecture for medical applications.

Document architecture is a fundamental element in the design architecture of picture archiving communication systems (PACS). This article gives an overview of a multimedia document architecture in terms of logical and layout structures and describes a method for organizing and modeling multimedia diagnostic reports. The proposed document model is based on the office document architecture (ODA) ISO standard with additional enhancements to satisfy the functionality required of future interworking PACS.

Documentation↗
PubMed2001

[A new video documentation system for rigid procto-rectoscopy].

INTRODUCTION: Disadvantages of rigid procto-rectoscope systems are the lack of sufficient visual documentation, data processing and the insufficient demonstration for educational purposes. Therefore a video documentation system for rigid procto-rectoscopy (Endovision Telecam SL) was developed. METHOD: For evaluation of the Endovision Telecam SL, the system was compared to the conventional technique over a 6-month period. RESULTS: The Endovision Telecam SL offers the advantage of flexible video-endoscopy and displays an excellent quality of documentation for rigid procto-rectoscopy. The handling of the system is slightly more time-consuming and difficult and the use is limited to cases without severe bleeding and stool contamination. CONCLUSIONS: The Endovision Telecam SL combines the advantages of flexible video-endoscopy in documentation, demonstration and data processing with the practibility of rigid instruments for procto-rectoscopy. In the present set-up the system is still limited to special indications and should be combined with conventional procedures.

Documentation↗
PubMed2004

[A structured report data set for documentation of echocardiographic studies--Update 2004].

A standardized documentation of echocardiographic studies is necessary to provide comparability of data and to realize software-based documentation and electronic communication, both essential for quality management in echocardiography.Therefore, the subgroup on "Standardization and LV function" of the working group on cardiovascular ultrasound of the German Cardiac Society developed a consensus report for documentation of echocardiographic studies, which was first published in 2000. This report represents the current update of the standardized documentation for echocardiography; its impact for quality management in conjunction with the "guidelines echocardiography" is discussed.

Data Collection↗
PubMed2006

Documenting comparability of clinical experience on the obstetrics and gynecology clerkship.

OBJECTIVE: This study was undertaken to develop a process that provides Liaison Committee on Medical Education (LCME)-required documentation of obstetric/gynecology (OB/GYN) clinical experience comparability and mid-clerkship feedback. STUDY DESIGN: Institutional review board approval was obtained. OB/GYN clerkship students at the University of North Carolina (UNCSOM) from June 2004 through June 2005 were given Clinical Activities Tools (CATs) to guide clinical work. CAT books listed Association of Professors of Gynecology and Obstetrics-recommended topics/procedures/skills and had a section for mid-clerkship feedback. Residents/faculty signed CAT sections to document student completion of topics/procedures/skills/feedback. CAT tool data were analyzed with univariate, chi2, and analysis of variance statistics. RESULTS: CATs were submitted by 81% (134/165) of students; 71% of CAT clinical activities had teacher signatures. CAT comparability was successfully documented for all topics/procedures/skills and for mid-clerkship feedback across sites and across rotation blocks. CATs provided active learning/communication opportunities and data used for curriculum revision. CONCLUSION: CATs facilitated successful documentation of clinical experience comparability and mid-clerkship feedback. The process is feasible and likely will be helpful to other institutions.

Clinical Clerkship↗
PubMed2005

Documentation of resuscitation events.

Resuscitation documentation assists health care professionals in trending patient status, determining what treatments may be most effective, and determining where opportunities for improvement may exist. An overview of what is known about resuscitation documentation is provided in this article, as are implications for future research related to documentation of resuscitation events. Use of the Utstein guidelines in determining essential elements of resuscitation documentation is also presented.

Documentation↗
PubMed2004

A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.

Documentation of clinical services within health care systems has become increasingly significant because greater amounts of information are now required by accrediting agencies, third-party payers, researchers, and others in their evaluation of patient care and because of the increasing emphasis on patient outcomes. Given the multiple users who depend on health care information in the patient record, it is imperative that clinical nutrition practitioners implement a standardized nutrition care process and language to document comprehensively and communicate meaningful information concerning their role in improving patient outcomes. A body of work has led to the development and adoption of a standardized nutrition care process for the dietetics profession. A standardized nutrition care process consistent with the scientific method and a standardized language are two essential components required to articulate a conceptual model for clinical nutrition practice and documentation and distinguish clinical dietetics' unique body of knowledge. The conceptual model serves as an organizing framework to standardize and guide nutrition practitioners' clinical judgments or critical thinking processes and document information linking nutrition care to patient outcomes.

Cost-Benefit Analysis↗
PubMedDate not supplied

Adaptive topological tree structure for document organisation and visualisation.

The self-organising map (SOM) is finding more and more applications in a wide range of fields, such as clustering, pattern recognition and visualisation. It has also been employed in knowledge management and information retrieval. We propose an alternative to existing 2-dimensional SOM based methods for document analysis. The method, termed Adaptive Topological Tree Structure (ATTS), generates a taxonomy of underlying topics from a set of unclassified, unstructured documents. The ATTS consists of a hierarchy of adaptive self-organising chains, each of which is validated independently using a proposed entropy-based Bayesian information criterion. A node meeting the expansion criterion spans a child chain, with reduced vocabulary and increased specialisation. The ATTS creates a topological tree of topics, which can be browsed like a content hierarchy and reflects the connections between related topics at each level. A review is also given on the existing neural network based methods for document clustering and organisation. Experimental results on real-world datasets using the proposed ATTS method are presented and compared with other approaches. The results demonstrate the advantages of the proposed validation criteria and the efficiency of the ATTS approach for document organisation, visualisation and search. It shows that the proposed methods not only improve the clustering results but also boost the retrieval.

Bayes Theorem↗
PubMed1992

Documenting nursing process in the perioperative setting. Continuity of care, patient evaluation.

Using our Perioperative Nursing Process form in addition to intraoperative and PACU flow sheets allows us to document the nursing process in a manner that satisfies the goals for documentation established by our committee. Because we place all forms in the patients' medical records, they are available for review by the JCAHO to prove that we comply with their standards and the standards of AORN and ANA. The nurses have been satisfied with the documentation system because it can be used efficiently and does not require redundant documentation as the patient transfers into each perioperative area.

Continuity of Patient Care↗
PubMed2003

Pre-printed 'do not attempt resuscitation' forms improve documentation?

OBJECTIVE: Do not-attempt-resuscitate orders are fundamental for allowing patients to die peacefully without inappropriate resuscitation attempts. Once the decision has been made it is imperative to record this information accurately. However, during a related research projected we noted that documentation was poor and we thought that the introduction of a pre-printed Do Not Attempt Resuscitation (DNAR) form would improve the documentation process. DESIGN: Two sets of identical research questions were applied retrospectively, 12-months apart, to notes of adult patients (>18 years) who had died during a hospital admission without under-going a resuscitation attempt. Between the first and the second audit, a new resuscitation policy that incorporated a pre-printed DNAR form was introduced into our hospital. RESULTS: A pre-printed DNAR form improved documentation when measured against; clarity of DNAR order (P=0.05), date decision was made/implementation (P=0.014), presence of clinician's signature (P=0.001), identification of the senior clinician making the decision (P< or =0.001) and justification for the DNAR decision (P< or =0.001). However, the pre-printed form made little improvement in encouraging patient involvement in the DNAR decision-making process (P=0.348). CONCLUSION: A pre-printed DNAR form can improve documentation significantly but it has little effect in encouraging patient involvement in the decision-making process.

Adolescent↗
PubMed1999

Informed consent documents for BRCA1 and BRCA2 screening: how large is the readability gap?

The decision to undergo testing for the BRCA1 and BRCA2 mutations, which are associated with an increased risk of breast and ovarian cancer, can have long-term consequences on women's lives. Women who decide to undergo such testing are required to sign informed consent documents, which indicate that they understand the test and its risks and benefits. These documents are generally written for advanced-level readers. However, the reading abilities of many women are substantially lower than the level of the consent forms, resulting in a 'readability gap'. This disparity suggests that women may not fully understand the documents they are asked to sign. The 'readability gap' poses the serious issues about informed consent, raising questions about institutional review boards and the effectiveness of the documents that are currently in use.

Adolescent↗
PubMed1999

Inaccurate documentation of HIV-positive status in adolescents visiting an urban emergency department.

PURPOSE: To identify the frequency of documentation of human immunodeficiency virus (HIV)-positive adolescents' serostatus during urban pediatric emergency room visits, and to examine possible differences between those whose HIV positive serostatus was and was not documented. METHODS: Between 1986 and 1996, 115 HIV-positive adolescents (41 male, 74 female) were followed for primary medical care at the Children's National Medical Center's adolescent HIV clinic (Burgess Clinic) in Washington, DC. A retrospective chart analysis of visits to the emergency room by these adolescent patients known to be HIV positive was conducted. RESULTS: Forty-nine of the HIV patients (ages 10-23 years) visited the hospital's emergency room a total of 124 times in the time following notification (range, 2 days to 15 years; mean, 2.6 years) of their seropositivity and joining the program. Twenty-nine of the patients had no HIV seropositivity recorded during one or more of their visits; this prevalence represents 38% of the 124 emergency room visits. Twenty of the HIV-positive emergency room patients had no seropositivity documented during any emergency department visit. Of all 124 visits, 45 involved potential health care worker exposure to the HIV virus. Diagnosis of acquired immunodeficiency syndrome, CD4 count, age, gender, and year of visit did not differ among those with and without HIV documentation. CONCLUSION: Human immunodeficiency virus-positive adolescents are seen in this emergency room and their records do not reflect their infection status. These data reinforce the need for universal precautions for every patient.

Adolescent↗
PubMed2002

Effective nursing documentation and communication.

OBJECTIVES: To identify the documentation and communication requirements an oncology nurse should follow to avoid negligence or malpractice suits. DATA SOURCES: Lexis, Medline, Westlaw, nursing and medical literature, and nursing legtal texts. CONCLUSIONS: Effective communication and documentation is an essential part of an oncology nurses' role and will reduce the risk of liability. IMPLICATIONS FOR NURSING PRACTICE: The old adage "not documented, not done" applies more today than ever before. Continuous, meticulous documentation and communication are essential for quality care as well as reduction of liability in every setting the oncology nurse practices.

Adolescent↗
PubMed2001

[Developing a cooperation model between 3 psychiatric clinics with the goal of quality assurance in mandatory treatment exemplified by restraint documentation].

Since 1996 three psychiatric hospitals have been working together closely in a team aiming at improving the quality management of coercive measures. The first comparison of documented restraints showed conspicuous differences in incidence and duration. Due to this, the group decided to document and to compare the incidence, duration and reason of restraints and the legal status and sociodemographic variables in the three hospitals over one year. Considerable deviations were found with regard to the number and duration of restraints and number of patients concerned. Hospital A (2622 admissions) registered 103 restraints of 53 persons whereas hospital B (5802 admissions) reported 254 restraints of 121 persons, hospital C (4252 admissions) finally, documented 621 restraints of 120 persons. Hypotheses giving reason for these findings are discussed. Furthermore, developments and changes aiming at reducing coercive measures and at complete and comparative documentation by co-operation of the three hospitals, are reported.

Adolescent↗
PubMed2001

[Opinions of staff in the trial phase of standardized documentation of complementary psychiatric services].

A computerised standardised documentation system for non-hospital based psychiatric and psychosocial care is being developed in Saxony. A range of non-hospital based services was involved in the development process. Staff members were interviewed concerning their experience in using the documentation system. Results showed a critical appraisal by staff members, emphasising particularly (a) the investment of time required, and (b) the perceived usefulness of the documentation which was considered to be limited. Besides staff members feared that data protection issues might be disregarded and that data would be used to cut expenditure. Findings are compared with other studies assessing staff attitudes towards data collection in mental health services. It is concluded that the study adds to the existing evidence of staff scepticism towards computerised standardised documentation systems.

Adult↗
PubMed2006

[3-dimensional documentation of wound-healing].

The objective evaluation of the course of wound-healing represents a substantial parameter for the quality assurance of a modern wound management in chronic wounds. Established procedures exclusively based on a two-dimensional measurement of the wound surface with planimetry or digital photo documentation in combination with a metric statement of size. Thus so far an objective method is missing for the evaluation of the volumes of chronic wounds. By the linkage of digital photography, optical grid by means of digital scanner and an image processing software in co-operation with the company RSI we were able to do an accurate 3-dimensional documentation of chronic wounds (DigiSkin). The generated scatter-plots allow a visual, computer-assisted 3-dimensional measurement and documentation of chronic wounds. In comparison with available systems it is now possible for the first time to objectify the volume changes of a chronic wound. On the basis of a case report of a female patient with an venous leg ulcer, which has been treated with a vacuum closure therapy before and after performing a mesh-graft transplantation, we would like to describe the advantages and the resulting scientific use of this new, objective wound documentation system in the clinical employment.

Combined Modality Therapy↗
PubMed1993

[Chemical and thermal eye burns in the residential area of RWTH Aachen. Analysis of accidents in 1 year using a new automated documentation of findings].

BACKGROUND: Until now there were no statistical data on the incidence and the prevalence of eye burns. Therefore we studied all patients coming to our hospital from the area of Aachen with eye burns during the time from September 1990 until August 1991. PATIENTS AND METHODS: All patients underwent a standardized examination including special history of the burning agent, industrial medical aspects and the employers liability insurance association. The documentation of the anterior eye segment pathology was scored separately for each eye encoded by location and special items. This documentation was worked up by the aid of a database (Filemaker II). 171 patients with eye burns were documented during one year. 65 patients had both eyes burned resulting in 236 documented records. RESULTS: The 171 accidents can be divided in 104 (61%) industrial accidents and 64 (37%) housework accidents. 3 accidents were of unknown origin. Classification of burns was scored according to Reim 1991. 208 (88%) eyes showed score I burns, 27 (11.5%) score II and only one patient showed a score III eye burn. We saw 121 (70%) male patients, 39 (23%) female patients and 11 children (7%). The main age group ranged from 16-45 years. 28% (n = 30) of all accidents happened in machine factories, which have thereby in our study the highest incidence of industrial accidents. CONCLUSION: By means of a one-year statistic we found that over 60% of all eye burns were industrial accidents, 28 in machine factories and 20% in service industries. 37% houseworks accidents are very difficult to prevent because of a deficit of safety rules.

Accidents, Home↗