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At least 541 records · Page 30Linked to original sources
PubMed2001

The impact of changes in HCFA documentation requirements on academic emergency medicine: results of a physician survey.

BACKGROUND: The Health Care Financing Administration (HCFA) has dramatically increased documentation and procedural supervision required by faculty in academic emergency departments (EDs). OBJECTIVES: To determine academic emergency medicine (EM) physicians' perceptions of the impact of HCFA documentation requirements (HDR) on teaching time, clinical efficiency, and job satisfaction. METHODS: An observational cross-sectional study was done using a survey of New England academic EM faculty from September to December 1999. E-mail surveys were followed by hard copy to nonresponders. Teaching time, clinical efficiency, and job satisfaction were rated on a five-point Likert scale. Yes/no questions about other possible benefits of HCFA regulations were asked. Frequency (95% CI) and chi-square analyses were performed. RESULTS: One hundred seventy-four of 233 (75%) responded. Eighty-nine percent (95% CI = 84% to 93%) of the respondents thought teaching time was somewhat or markedly decreased by changes in HDR (somewhat 46%, markedly 43%). Seventy-nine percent (95% CI = 73% to 85%) believed clinical efficiency was somewhat or markedly decreased by changes in HDR (somewhat 49%, markedly 30%). Eighty percent (95% CI = 73% to 86%) reported somewhat or markedly decreased job satisfaction due to changes in HDR (somewhat 56%, markedly 24%). Twenty-one percent (95% CI = 15% to 27%) believed changes in HDR had improved patient care by requiring increased patient supervision. Forty-eight percent (95% CI = 40% to 56%) thought that changes in documentation requirements had decreased medicolegal risk by improving patient documentation. CONCLUSIONS: Most academic EM physicians in New England perceive that HDR have decreased clinical efficiency, teaching time, and job satisfaction. These findings suggest that changes in HDR may have a substantial impact on many different aspects of emergency care provided in academic settings.

Academic Medical Centers↗
PubMedDate not supplied

Pain management: improving documentation of assessment and intensity.

As a result of standards published by the Joint Commission on Accreditation of Healthcare Organizations, there is new emphasis in the area of pain management. This pilot study was conducted to assess the visibility of pain management through documentation; the effect of implementing new tools (forms) was measured to determine whether they improve documentation of pain management assessment and intensity. A retrospective chart review was conducted to determine presence of this documentation. This study found that it is possible to improve the quality of information related to pain assessment through the development of explicit documentation tools.

Adolescent↗
PubMed2001

Tobacco industry efforts at discrediting scientific knowledge of environmental tobacco smoke: a review of internal industry documents.

STUDY OBJECTIVE: Using tobacco industry internal documents to investigate the use of tobacco industry consulting scientists to discredit scientific knowledge of environmental tobacco smoke (ETS). DESIGN: Basic and advanced searches were performed on the Philip Morris, Tobacco Institute, R J Reynolds, Brown and Williamson, Lorillard, and the Council for Tobacco Research document web sites, with a concentration on the years 1985-1995. Guildford depository files located on the Canadian Council on Tobacco Control website were also searched. The documents were found in searches undertaken between 1 March and 30 June 2000. MAIN RESULTS: The industry built up networks of scientists sympathetic to its position that ETS is an insignificant health risk. Industry lawyers had a large role in determining what science would be pursued. The industry funded independent organisations to produce research that appeared separate from the industry and would boost its credibility. Industry organised symposiums were used to publish non-peer reviewed research. Unfavourable research conducted or proposed by industry scientists was prevented from becoming public. CONCLUSIONS: Industry documents illustrate a deliberate strategy to use scientific consultants to discredit the science on ETS.

Air Pollution, Indoor↗
PubMed2002

Tax, price and cigarette smoking: evidence from the tobacco documents and implications for tobacco company marketing strategies.

OBJECTIVE: To examine tobacco company documents to determine what the companies knew about the impact of cigarette prices on smoking among youth, young adults, and adults, and to evaluate how this understanding affected their pricing and price related marketing strategies. METHODS: Data for this study come from tobacco industry documents contained in the Youth and Marketing database created by the Roswell Park Cancer Institute and available through http:// roswell.tobaccodocuments.org, supplemented with documents obtained from http://www.tobaccodocuments.org. RESULTS: Tobacco company documents provide clear evidence on the impact of cigarette prices on cigarette smoking, describing how tax related and other price increases lead to significant reductions in smoking, particularly among young persons. This information was very important in developing the industry's pricing strategies, including the development of lower price branded generics and the pass through of cigarette excise tax increases, and in developing a variety of price related marketing efforts, including multi-pack discounts, couponing, and others. CONCLUSIONS: Pricing and price related promotions are among the most important marketing tools employed by tobacco companies. Future tobacco control efforts that aim to raise prices and limit price related marketing efforts are likely to be important in achieving reductions in tobacco use and the public health toll caused by tobacco.

Adolescent↗
PubMed1999

[How much preoperative information? - How can it be documented?].

Preoperative information for patients and documentation of this information are becoming increasingly significant. Opinions diverge especially on how to document the information provided, the information protocol being only an ancillary element. The patient must be in a position to make an informed decision without suffering any prejudice. Information protocols relating to treatment, that is to the operation, aim at ensuring the quality of the treatment and at documenting the information provided. A scheme of the operation is an important element of this information. Twenty-one presurgical information protocols have been tested in a pilot phase and are still being evaluated by a patients' association. Information and documentation concepts need to be set up by professional societies before insurance companies and governmental offices start getting involved.

Documentation↗
PubMed2005

The Swedish DOC system--an attempt to combine documentation and self-evaluation.

This article addresses the issue of how documentation can become a regular and competence-raising activity in treatment settings. A documentation system in Sweden (the DOC system) is used as an illustrative example. Two propositions are put forward and discussed: it is important that (1) the documentation be in accordance with the interests of the practitioners, and (2) that the documentation be used for self-evaluation, in order to enhance the practitioners' competence. Based on experiences using the DOC system, some general observations about how to implement the forms and self-evaluation are presented. Finally, some research prospects are outlined.

Clinical Competence↗
PubMed1996

An investigation of documentation submitted by university students to verify their learning disabilities.

To become eligible for support services at the postsecondary level, students with learning disabilities (LD) must submit documentation to verify the existence of a specific LD. The documentation submitted over a 5-year period by 415 students to a large public research university that offers a comprehensive program for students with LD was examined. An analysis of the documentation indicates that serious problems exist in the type and quality of evaluation reports. Problems include flaws in the comprehensiveness of the assessments, and the use of questionable instruments for this population. Recommendations for establishing guidelines for acceptable documentation are offered.

Adolescent↗
PubMedDate not supplied

The tobacco industry's response to the COMMIT Trial: an analysis of legacy tobacco documents.

We analyzed internal tobacco industry documents that describe the industry's response to the Community Intervention Trial for Smoking Cessation (COMMIT), a multi-center community-based tobacco intervention project funded by the National Cancer Institute from 1988 to 1992. Our analysis of documents from the Legacy Tobacco Documents Library (www.legacy.library.ucsf.edu) suggests that the tobacco industry reacted to COMMIT by (1) closely monitoring trial activities, (2) confronting COMMIT in communities where it was most active, (3) distorting COMMIT findings on underage smoking data reported in the media, and (4) using COMMIT activities as practice to strengthen their attack against the subsequent ASSIST trial, falsely accusing both studies of illegal political lobbying with taxpayers' money. The tobacco industry closely monitored COMMIT activities and organized local responses to findings and activities perceived as threatening to the industry's public image or interests. Although we could not document a concerted attack by the tobacco industry that impacted the results of the COMMIT trial, data suggest that the industry used COMMIT as a learning opportunity to mount a well orchestrated and potentially damaging response to the larger American Stop Smoking Intervention Study for Cancer Prevention Trial.

Adolescent↗
PubMed1994

Documenting pharmaceutical care: creating a standard.

OBJECTIVE: To examine the need for a standardized, systematized approach to document patient pharmacotherapy, workable in all pharmacy practice settings, and to propose a model to meet the identified needs. DATA SOURCE: A MEDLINE search was conducted, in addition to an assessment of current practices and a review of known sources of pharmacotherapy/pharmaceutical care evaluation and documentation methodology. CONCLUSIONS: Pharmacy lacks a universally accepted, standardized, systematized approach to document the evaluation of a patient's pharmacotherapy. An approach is presented that distills the concepts of pharmaceutical care into a manageable documentation format and provides a customization of the medical history and physical examination/subjective-objective-assessment-plan system to meet the unique needs of pharmacy. This approach provides a convenient format for notes for all pharmacists, applicable in any practice setting. It provides a starting point for decisions on what pharmacy wants and accepts as a standard to provide continuity of pharmaceutical care to patients, uniform communication with healthcare colleagues, appropriate instruction to students, data analysis to demonstrate the value of services, and needed guidance to software vendors, medical records departments, and third-party payers.

Data Collection↗
PubMed2000

Teaching patients about kidney transplantation: documentation.

Increasing demands are being placed on transplant nurse coordinators for more precise documentation of their teaching of kidney transplant patients, but the amount of time nurses have for this added documentation remains unchanged or has diminished. After a thorough review of the literature, our transplant team found no patient teaching documentation format that assisted us in overcoming the problem of increased demands. Consequently, following the Joint Commission on Accreditation of Healthcare Organization standards, we developed a Renal Transplant Patient Teaching Record that has assisted our team in documenting the pre- and post-transplant patient teaching that we complete.

Documentation↗
PubMed2006

The work the document does: research, policy, and equity in health.

At the center of the politics of health equity, in many countries and circumstances, stands a signal report of research. This article is concerned with what might be described as the architecture of such documents, including how they are produced and organized and the relationships they demonstrate with others that parallel, precede, and succeed them. The article examines how scientific and political authority is established and comments on the evidence of cross-national learning that these documents reveal. It discusses differences in how the problem of health equity is constructed in different countries and how research findings are converted into policy recommendations. It begins to trace a process of implementation by noting how these documents are referred to and written about. The argument is that the politics of health equity are expressed or realized in the documents and reports, which are its principal vehicle. This is not to claim that there is no world beyond the text or that the world somehow is a text, but that to fully understand that world we must understand the text and the work it does.

Documentation↗
PubMedDate not supplied

The importance of wound documentation and classification.

Good wound documentation has become increasingly important over the last 10 years. Wound assessment provides a baseline situation against which a patient's plan of care can be evaluated. A number of documents have been implemented including the 'Code of Professional Conduct for Nurses, Midwives and Health Visitors' (UKCC, 1992), the 'Post-registration Education Project' (UKCC, 1997), 'Standards of Records and Record Keeping' (UKCC, 1998), and 'Keeping the Record Straight' (NHS Executive (NHS E), 1993). These documents require nurses to maintain their professional knowledge and competence, and to recognize any deficiency in their knowledge. Having recognized any deficiency they should read the relevant literature and/or attend a study day on wound care. Nursing records are the first source of evidence investigated when a complaint is made. Wound assessment is very complex and a standardized approach to evaluation needs to be adopted. Such evaluation should encompass colour classification, wound measurement, and classification of tissue type present in the wound. There are numerous methods of measuring wounds; these range from the simple, such as manual estimation by means of a ruler or wound tracing, to the more technical procedures, e.g. computer, image analysis, and colour imaging using hue saturation and intensity. Photography, in conjunction with nursing notes, provides a very good form of wound documentation and can provide clear evidence if required for legal cases.

Diagnosis-Related Groups↗
PubMed1995

Improving the E coding of hospitalizations for injury: do hospital records contain adequate documentation?

OBJECTIVES: Incomplete external cause of injury (E) coding limits the usefulness of hospital discharge data sets for injury surveillance and research. Hospital medical records were examined to determine whether they contained adequate cause of injury documentation to allow for more complete E coding of injury discharges. METHODS: Medical records for a sample of discharges involving a principal diagnosis of injury from the Uniform Hospital Discharge Data Set for Rhode Island were selected. We assigned E codes to these discharges and compared our E codes with those of the discharge data set. RESULTS: Documentation of cause of injury in the medical records was sufficient to allow assignment of a specific E code to 70% of the injuries for which no E codes or vague E codes were submitted on the Uniform Hospital Discharge Data Set. It was estimated that specific cause of injury documentation is available in the medical records of 80% of all injury discharges in Rhode Island; for approximately 90%, an E code describing at least the broad cause of injury could be assigned. CONCLUSIONS: Rates of E coding can be substantially increased by making better use of existing documentation in medical records.

Abstracting and Indexing↗
PubMedDate not supplied

New role of a medical documentation system.

Architecture of a new medical documentation system (MDS) is proposed. First, we studied the traditional MDS in terms of organizational structure, main functions, means (resources) and personnel. Special emphasis is given to the information retrieval (IR) system which is the kernel of a MDS. Then, some achievements of information technology is summarized, and concept of a mixed IR system which is the kernel of the new system is presented. New architecture is then presented. Units which compose the entire system are: host documentation centre, local documentation centres, and documentation units. Eventually, objective and features of every part are discussed.

Database Management Systems↗
PubMed1997

Documenting progress in home care.

The home is an ideal environment for the practice of occupational therapy. However, the tumultuous health care environment of the late 1990s requires practitioners to take special care not only in delivering effective services, but also in documenting the delivery of skilled care. Documentation is the bridge between the delivery of occupational therapy services in the home and the approval for reimbursement of services by third-party payers. This article presents principles for writing reimbursable progress notes for home care that are based on Medicare documents related to occupational therapy. Application of these principles can improve efficiency and excellence in practitioners' documentation skills.

Documentation↗
PubMed2006

Documentation of surgical specimens using digital video technology.

CONTEXT: Digital technology is commonly used for documentation of specimens in anatomic pathology and has been mainly limited to still photographs. Technologic innovations, such as digital video, provide additional, in some cases better, options for documentation. OBJECTIVE: To demonstrate the applicability of digital video to the documentation of surgical specimens. DESIGN: A Canon Elura MC40 digital camcorder was used, and the unedited movies were transferred to a Macintosh PowerBook G4 computer. Both the camcorder and specimens were hand-held during filming. The movies were edited using the software iMovie. Annotations and histologic photographs may be easily incorporated into movies when editing, if desired. RESULTS: The finished movies are best viewed in computers which contain the free program QuickTime Player. Movies may also be incorporated onto DVDs, for viewing in standard DVD players or appropriately equipped computers. The final movies are on average 2 minutes in duration, with a file size between 2 and 400 megabytes, depending on the intended use. Because of file size, distribution is more practical via CD or DVD, but movies may be compressed for distribution through the Internet (e-mail, Web sites) or through internal hospital networks. CONCLUSIONS: Digital video is a practical, easy, and affordable methodology for specimen documentation, permitting a better 3-dimensional understanding of the specimens. Discussions with colleagues, student education, presentation at conferences, and other educational activities can be enhanced with the implementation of digital video technology.

Documentation↗
PubMedDate not supplied

Compliance with Medicare's chart documentation requirements in evaluation and management (E/M) coding.

1. Use of forced entry charts facilitates proper chart documentation and helps assure compliance with Medicare's chart documentation requirements. 2. Nurses and technicians are responsible for up to two-thirds of the required chart documentation in the patient's record. 3. Performance and documentation are not synonymous. There must be a meticulous written record of what was performed as well as negative and positive findings for both the history and the examination portions of the exam. Recording possible, probable, and rule/out diagnoses enhances the level of complexity of medical decision-making.

Abstracting and Indexing↗
PubMed1999

[Onco-PET: lesion detection by monitor versus standardized film documentation].

AIM: Lesion detection and localization of 2-[18F]fluoro-2-deoxy-D-glucose (F-18-FDG) Onco-PET-Investigations are usually performed on-line at the computer display. The aim of the present study was to evaluate the clinical efficacy of a standardized film documentation as an alternative approach. METHODS: 100 Onco-PET-investigations without attenuation correction were analyzed with regard to number and localization of lesions suspicious of malignancy. A standardized documentation on film was developed including 1. transversal slices of the brain, 2. coronal slices and maximum-intensity-projections (MIPs) of the head/neck region and 3. of the trunk and 4. MIPs of the legs. These transparencies were analyzed at the light box. An additional analysis on the computer display was performed slice by slice in coronal, transversal and sagittal directions for the whole body. RESULTS: A total of 315 lesions were detected in 100 patients. In 96/100 patients the two modalities agreed both in number and localization of tumor-suspicious lesions. 7 lesions in the legs of 3 patients didn't show when interpreting the films (MIPs only). In 2/100 patients additional analysis on the computer display caused a change in the localization of 9/315 lesions. 8 of these were located in the legs. When adding coronal slices for the documentation of the lower extremities all the lesions were shown. Moreover, all lesions were localized correctly except one clinically non-relevant change of localization out of a total of 322 lesions. CONCLUSION: The newly developed standardized documentation supports the concept of film reading and reporting of onco-PET investigations, restricting an additional on-line analysis to rare cases only. Furthermore, the intention of the "Arbeitsgemeinschaft Standardisierung" (work group standardisation) are met, i.e. to ease analysis of follow-up studies acquired at different places.

Documentation↗