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At least 523 records · Page 29Linked to original sources
PubMed2006

Traditional toxicity documentation of Chinese Materia Medica--an overview.

Documentation of Chinese materia medica (CMM) dates back to around 1,100 BC when only dozens of drugs were first described. By the end of the 16th century, the number of drugs documented had reached close to 1,900. And by the end of the last century, published records of CMM have reached 12,800 drugs. The recorded traditional information includes toxicities, incompatibilities, cautions, precautions and contraindications. Thus, contrary to a general misconception, toxicity data on Chinese herbs exist and are not meager. If consulted properly before embarking on a study of CMM, it will save researchers much time and efforts and the frustration of not obtaining consistent or expected results. The history of documentation is reviewed with examples of major classic and contemporary works highlighting and emphasizing the manner in which CMM toxicities have traditionally been documented through clinical experience as opposed to most modern toxicity data that are based on animal experimentation.

Documentation↗
PubMed2000

Evaluation of nursing documentation. A comparative study using the instruments NoGA and Cat-ch-ing after an educational intervention.

In this article we describe the results of a comparative study focusing on the evaluation of nursing documentation before and after an educational intervention. An additional aim is to report the results of a comparison between quality measurements of nursing documentation using the examination instruments NoGA and Cat-ch-ing and, against this background, to recommend an instrument for future examinations. The educational intervention was directed towards nurses at Helsingborg hospital/health care district. The intervention, which comprised supervision, group sessions, lectures and field trips, covered a period of two years and was built on a learning model. In all, the data material examined included 515 nursing records collected from 52 units. The study reports on a comparison of the examination results from four different clinics for the years 1994 and 1997. The results show a statistically significant difference between the four clinics before the intervention, a difference that disappeared after the intervention. Furthermore, the results show a statistically significant improvement in documentation after the intervention. For future examinations, it is recommended that the examination instrument Cat-ch-ing should be used and that methods for examination of the content of the documentation must be developed.

Documentation↗
PubMed1996

Quality of pharmacists' documentations in patients' medical records.

Training pharmacists to appropriately document patient-specific problems and recommendations in patients' medical records and subsequent monitoring of pharmacist-written documentation are described. The medical staff of a tertiary care teaching hospital recommended that pharmacists be allowed to write in the permanent portion of patients' medical records. A six-month pilot program was approved to train pharmacists in writing chart notes. Notes would be assessed according to the following criteria: necessity (i.e., a chart note was the appropriate means of communication), clarity, legibility, completeness, correct format, and lack of judgmental language. Initial training was by physicians from the pharmacy and therapeutics committee, with more extensive training by a committee composed of clinical and administrative pharmacists. After training ended, each pharmacist's first few notes were reviewed by a member of the pharmacy committee. The quality of pharmacist-written notes is reviewed quarterly. The first quarterly evaluation and another review 1 1/2 years later showed that all pharmacist notes met all of the established criteria. A multidisciplinary approach was effective in training pharmacists to document interventions appropriately in patients' permanent records. Ongoing monitoring ensures the continuing quality of such documentation.

Documentation↗
PubMed1996

Using pharmacists' documentation of clinical activities to reclaim employees and reposition the department.

The use of documentation on pharmacist clinical activities to encourage greater hospital investment in a department is described. From 1983 through 1988, the number of full-time-equivalent (FTE) positions in the pharmacy department at a 468-bed medical center was reduced from 63 to 39.4. To cope with the challenge of a sharply reduced staff, the department established a permanent pharmacy-nursing task force, developed a pharmacy strategic plan, used total quality management, recruited the best staff possible when openings appeared, and held staff retreats. In addition, measures were taken to begin documenting all pharmacist clinical activities online. As data were accumulated, it became clear that more pharmacist involvement in patient care areas was needed and that more resources would be necessary to achieve that. Presentations were made to hospital administration to demonstrate the existing and potential contributions of the department; the presentations drew heavily on the clinical documentation. Formal reports were also submitted. As a result, the department received approval for a pharmacist career ladder, an increase of 1.6 pharmacist FTEs for the evening shift, a large salary-range adjustment for staff pharmacists, and an increase of 1 pharmacist FTE to focus on antimicrobial use. A pharmacy department successfully used documentation of its clinical activities to make a case to administration for reclaiming some of the pharmacist FTEs lost through downsizing.

Computer Systems↗
PubMed2005

The art of skin and wound care documentation.

PURPOSE: To provide physicians and nurses with an overview of strategies for descriptive documentation of skin and wound assessments and interventions. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in learning about strategies for documenting skin and wound assessments and interventions. OBJECTIVES: After reading the article and taking the test, the participant will be able to: 1. Describe documentation related to the use of risk assessment and manual assessment tools. 2. Describe documentation related to the use of skin and wound assessment tools.

Clinical Competence↗
PubMed1981

A European network of documentation and information in rehabilitation: its necessity and concept.

Both, the practical rehabilitation process and rehabilitation as a field of theory, research and training, can be realized and promoted only through close communication of professionals from various disciplines and levels in different countries. An interdisciplinary and international network of documentation and information is a prerequisite to such cooperation. Differentiated assessment, qualitative analysis and filtering, classified storing and aggressive and multivariate dissemination of information would be the major functions of the network. Both specialists from the various scientific disciplines of rehabilitation and documentation and information specialists would have to fulfill these functions. A corresponding European network should be brought about by close cooperation of national centers for documentation in rehabilitation, of centers specializing in various basic disciplines and different kinds of disabilities, and a European Center for Documentation and Information in Rehabilitation, which would centrally store and disseminate information both from the more specialized centers in Europe, and from corresponding centers in other continents. The necessary agreements between centers in various countries and continents should be brought about with the help and under the auspices of an international organization, like Rehabilitation International.

Documentation↗
PubMed1992

Streamlining patient care documentation.

One of the most challenging realities faced by practicing nurses is patient care documentation. Miller and Pastorino have estimated that nurses currently spend more than 15% of their day in documentation activities. This documentation is essential in describing the care provided and the patient's response to that care. Today, a concise, efficient, and effective documentation system is urgently needed. The answer is the merging of the traditional patient care plan with the nursing care management MAP. This merger combines the proactive approach of multidisciplinary care found in nursing case management with the best concepts of the care plan.

Arizona↗
PubMed2000

Forms facilitating primary care documentation.

Documentation is a time-consuming but vital component of patient care. As health care providers function under increasing time constraints, well-designed forms can help simplify and improve the documentation process. Patient record forms can help clinicians identify essential points of the history and physical examination and can provide anticipatory guidance. One classification system frequently used by primary care providers is the evaluation and management (E/M) code system. E/M codes are a subset of the Current Procedural Terminology codes developed by the American Medical Association to standardize the terminology used to describe medical and surgical services. This article presents one documentation system that primary care providers may find effective in their documentation efforts.

Abstracting and Indexing↗
PubMedDate not supplied

Evaluating the impact of computerized clinical documentation.

A computerized system for care planning and documentation of patient care was initiated at a western teaching hospital, using the framework of Nursing Interventions Classification and Nursing Outcomes Classification standardized languages. The software integrates care planning and documentation, and includes both order entry as well as a charting application. Prior to initiating the project, a study was conducted to evaluate staff attitude toward computerization, time needed for documentation, and comprehensiveness of charting entries. Data from staff surveys, observations, and chart audits conducted pre- and post-computer project implementation demonstrated that the staff attitudes toward computers were less positive, the time required for charting was unchanged, and there were improvements in how completely the nurses documented charting elements.

Adult↗
PubMedDate not supplied

Utilizing the language of Jean Watson's caring theory within a computerized clinical documentation system.

The healthcare facility described in the following article is part of an eight-hospital organization that adopted Watson's Theory of Caring as part of their nursing philosophy. According to Watson, this theory is an attempt to find and deepen the language specific to nurse caring relations and its many meanings. Yet during the implementation of the theory within the setting described, it was noted that there was no mechanism in the current documentation system for clinical nursing staff to document the patient experience using any language specific to the theory. Nursing members recognized an opportunity to develop a new context in charting during an extensive clinical documentation system upgrade. A discussion of the steps taken and the results within the clinical documentation system supporting the newly adopted caring philosophy are summarized here.

Altruism↗
PubMedDate not supplied

The art of skin and wound care documentation.

PURPOSE: To provide physicians and nurses with an overview of strategies for descriptive documentation of skin and wound assessments and interventions. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in learning about strategies for documenting skin and wound assessments and interventions. OBJECTIVES: After reading the article and taking the test, the participant should be able to: 1. Describe documentation related to the use of risk assessment and manual assessment tools. 2. Describe documentation related to the use of skin and wound assessment tools.

Documentation↗
PubMed2006

Wound documentation: managing risk.

PURPOSE: To provide the physician and registered professional nurse with an understanding of consistent wound documentation and the potential for legal issues to arise. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in better understanding and improving policies and procedures related to wound documentation. OBJECTIVES: After reading the article and taking the test, the participant should be able to: 1. Discuss wound assessment and documentation relative to current practices and potential legal implications. 2. Describe recommendations to improve the consistency and accuracy of wound assessment and documentation.

Chronic Disease↗
PubMed2005

Risk management strategies in physical therapy: documentation to avoid malpractice.

PURPOSE: This article aims to highlight the importance of a complete and accurate medical record as it pertains to potential risk exposure in the outpatient physical therapy profession. DESIGN/METHODOLOGY/APPROACH: Basic charting rules, correction and alteration recommendations, documentation of telephone conversations, informed consent, exculpatory release forms and incident reports are discussed. Basic risk management strategies are reviewed that may reduce outpatient physical therapy practitioners' malpractice exposure. FINDINGS: The authors contend that quality and thorough documentation is as important as the quality of the care that is delivered to patients, since medical records are legal documents and serve as valuable evidence as to what transpired between patients and the healthcare providers. ORIGINALITY/VALUE: Practical documentation strategies are described in a manner that will inform physical therapists of their legal obligations relating to patient care.

Ambulatory Care↗
PubMed1997

Implementation of a documentation management system for quality assurance in a university hospital.

Development and implementation of guidelines constitutes the basis of quality management systems for any organization. The authors have studied the internal documentation produced by professionals on 88 functional units of a university hospital. Reveals the existence of many documents concerning quality of care with an average of 102 available procedures or protocols per unit. However, this documentation is badly organized, making it difficult to consult and to put into practice. The results of this study were provided to other professionals at our hospital in order to make them aware of the necessity of rigorous document management. We have also written and sent recommendations for drawing up procedures and implementing an efficient documentary management system. This effort complements development of the hospital quality assurance plan.

Clinical Protocols↗
PubMed2004

Image restoration of arbitrarily warped documents.

We present a framework for acquiring and restoring images of warped documents. The purpose of our restoration is to create a planar representation of a once planar document that has undergone an arbitrary and unknown rigid deformation. To accomplish this restoration, our framework acquires and flattens the 3D shape of a warped document to determine a nonlinear image transform that can correct for image distortion caused by the document's shape. Our framework is designed for use in library and museum digitization efforts where very old and badly damaged manuscripts are imaged.

Algorithms↗
PubMed1994

Evaluation of nursing process documentation.

Following the introduction of a nursing process and associated documentation in one hospital, an attempt was made to evaluate the effectiveness of the documentation as a record of the nursing process. Two questionnaires were developed, based on previous research in this field, one for the assessment of the documentation, and the other to assess the attitudes and practices of the ward sisters regarding its implementation. The findings indicated that, generally, the assessment phase of the process was poorly documented and that many psychological and social problems were not addressed as well as others. The interventions were relevant but contained little detail. The evaluation section was fair but updating and re-assessment where relevant were poor. Some sisters seemed to display a lack of understanding of the principles or the practice of the process, despite in-service education. Lessons to be learnt from the exercise are suggested.

Activities of Daily Living↗
PubMed2000

Documentation of health risks and health promotion counseling by emergency department nurse practitioners and physicians.

PURPOSE: The purpose of this study was to examine medical record documentation of health risk factors and health promotion discharge counseling by nurse practitioners and physicians practicing in an emergency department in the U.S. midwest. METHODS: In this two-group comparative study researchers examined random-stratified medical records 305 nonacute ambulatory patients for selected health risk factors, including smoking, alcohol use, elevated blood pressure, obesity, and dental caries. RESULTS: Fifty-nine percent of this sample of relatively young adults (mean age = 33) had one or more health-risk factors. According to medical record documentation, only 22% of these adults, with nonacute problems, received health promotion counseling. Multivariate analyses indicated that nurse practitioners were slightly more likely to provide smoking cessation counseling than were physicians. CONCLUSIONS: Many opportunities for identification of health risks and follow-up counseling, as recommended in Healthy People 2000 and by the U.S. Preventive Services Task Force, were not documented. To meet the new goals of Healthy People 2010, health care providers in all settings should identify health risk factors and document health promotion counseling during every patient encounter.

Adult↗
PubMed2001

Emergency medicine resident patient care documentation using a hand-held computerized device.

OBJECTIVE: To determine whether emergency medicine (EM) resident documentation of procedures, patient encounters, and patient follow-ups improved after implementation of a personal digital assistant (PDA) hand-held recording system. METHODS: All first-year EM residents were provided a PalmV (Palm, Inc., Santa Clara, CA) PDA. A customized patient procedure and encounter program was constructed using Pendragon Forms (Pendragon Software Corporation, Libertyville, IL) and loaded into each PDA. Residents were instructed to enter information on patients who had any of 21 procedures performed or were considered to be clinically unstable. These data were downloaded to the residency coordinator's desktop computer. The mean number of procedures, encounters, and follow-ups performed per resident were then compared with those of a group of 36 historical controls from the three previous first-year resident classes who recorded the same information using a handwritten card system. Data from the historical controls were combined and the means of each group were compared by Student's t-test. RESULTS: Mean documentation of three procedures was significantly increased in the PDA group versus the index card system: conscious sedation 5.8 vs. 0.03 (p < 0.000005), thoracentesis 2.2 vs. 0.0 (p = 0.002), ultrasound 6.3 vs. 0.0 (p = 0.002). The mean numbers of pericardiocenteses and unstable pediatric surgical patient evaluations were significantly decreased in the hand-held group [from 1.2 to 0.4 (p = 0.03) and from 9.1 to 2.2 (p = 0.02), respectively]. Patient follow-up documentations were not statistically different between the two groups. CONCLUSIONS: Use of a hand-held PDA was associated with an increase in first-year EM resident documentation in three of 20 procedures and a decrease in one procedure and the number of unstable surgical pediatric patient resuscitations. The overall time savings in constructing a resident procedure database, as well as the other uses of the PDAs, may make transition to a hand-held computer-based procedure log an attractive option for EM residencies.

Adult↗