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At least 577 records · Page 32Linked to original sources
PubMed1992

[The follow-up of the orthodontic treatment of facial cleft patients with the Göttingen computer-supported documentation system].

The care of patients with cleft lip, alveolus, and palate demands supervision of the development and progress over a long period of time. It also requires a standardized and systematic basic documentation. In our cleft center the documentation is summarized on one sheet of paper with DIN-A4 formation (297 x 210 mm). The use of electronic data processing improves the documentation. The storage of general and medical data has been supplemented by a personal computer system, PC-System. Five years after developing of this computer aided documentation system several patients are shown as examples for the application of this system for longterm control patients with cleft lip, alveolus, and palate.

Child↗
PubMed1992

Documentation: incorporating the nursing process.

The nursing process is a formalized, systematic approach to providing and documenting nursing care and is an integral component of any documentation. This article discusses the nursing process and its relation to ambulatory surgery documentation, as well as the impact of standards of health care organizations on the documentation process for the perioperative patient in the ambulatory surgery setting.

Ambulatory Surgical Procedures↗
PubMed1964

[AN ATTEMPT AT AUTOMATION OF DOCUMENTATION IN MEDICINE].

Since there is still little mechanization in medical documentation, it seemed interesting to study an attempt at automation in a medical specialty, cancerology. The author explains the difficulties which derive from the multidisciplinary nature of the specialty itself and from the diversity of its users' needs. The system used is Filmorex, which is described in some detail. The author then examines the problems connected with the development of a documentation language and describes an attempt to solve these problems in a documentation center of moderate size (10,000 documents per year).

Abstracting and Indexing↗
PubMed2003

[Documentation of good distribution practice of medicines and its implementation in Lithuanian drug distribution companies].

Good Distribution Practice of medicinal products for human use is a quality warranty system, which includes requirements for purchase, receiving, storage and export of drugs, intended human consumption. A drug is a specific product and its mishandling is dangerous to human health and life. Therefore it is necessary to strictly control the movement of the drug from the producer to the consumer so that poor quality drugs do not have access to the market. Good Distribution Practice rules set the general requirements for good wholesale distribution practice of drugs, intended for human consumption. In order for company to meet the specified requirements, the drug distribution company must have all suitable and necessary premises, machinery, equipment, the required number of employees and specified documentation. The preparation of the Good Distribution Practice documentation is one of the most important and complex aspects when implementing the Good Distribution Practice in the companies. The article deals with the analysis of results obtained during the research of drug distribution companies in Lithuania. The research revealed that drug distribution companies put emphasis on the equipment of storage premises. Less attention is being paid to the preparation of the documents of Good Distribution Practice. The article thus presents the analysis of Good Distribution Practice documents prepared by the drug distribution companies.

Documentation↗
PubMed1992

Use of medication orders for monitoring prescribing and documenting consultations.

A study of the consultations performed by pharmacists under a documentation system that avoids extra paperwork is described. Pharmacists at a tertiary-care teaching hospital developed a system under which the medication order itself is used to capture the information needed for documenting pharmacist consultations. Orders requiring consultation are flagged, and the consulting pharmacist makes a note on the prescription detailing the problem and the outcome of communication with the prescriber. These orders are collected daily and photocopied. To evaluate the system, data on the consultations and the drug orders they represented were collected from July 1990 through June 1991. The potential of the flagged order, if implemented, to adversely affect patient outcome was used to classify the consultations. During the 12-month period, 1031 clinically significant consultations were documented. The rate of acceptance by prescribers was 83%. Orders with potentially fatal or severe consequences accounted for 18.4% of the consultations. The medical service had the largest percentage of consultations, followed by the psychiatric, surgical, and obstetrics and gynecology services. The data were used to show the positive impact that the pharmacy department has on patient outcomes. A system for documenting pharmacist consultations that avoided the use of forms was simple to use and showed a high rate of acceptance of recommendations.

Clinical Pharmacy Information Systems↗
PubMed2005

Documentation of family violence in New Zealand general practice.

AIM: To determine the rate of family violence documented during general practice consultations and describe clinical presentations. METHOD: A dataset of 447,809 computerised consultations involving 143,634 patients from 41 general practices throughout New Zealand was examined to identify consultations recording family violence issues. The documentation rate was determined and the subset analysed. RESULTS: A subset of 337 consultations from the 447,809 examined (0.075%) involved a family violence issue. This subset included 311 patients, 0.2% of the 143,634 patients in the original 6-month dataset. 225 (81%) of the patients in the subset were female. Family violence was the main reason for presentation in 137 (40%) consultations. The perpetrator was identified as the partner in 134 (40%) consultations, as the parent in 54 (16%) consultations and the patient identified themselves as the possible abuser in 17 (5%) consultations. Physical abuse (42%) and sexual abuse (26%) was most commonly mentioned. Past abuse (42%) was discussed as often as current abuse (41%). Depression and anxiety disorders were documented in 59 (18%) of these consultations. CONCLUSIONS: The number of consultations documenting family violence is low in this dataset. Such information is not always recorded, however GPs can also be reluctant to ask about, and patients can be hesitant to disclose family violence issues. The number of consultations involving the perpetrator was higher than expected. GPs require training to deal with both the victim and the perpetrator of family violence.

Documentation↗
PubMedDate not supplied

A systematic review of the scientific documentation of fixed partial dentures made from fiber-reinforced polymer to replace missing teeth.

PURPOSE: Many restorative systems have become commercially available that are based on fiber-reinforced polymers (FRP) for production of fixed partial dentures. However, the clinical documentation of their use has not been systematically reviewed and critically appraised. This systematic review aimed to identify the scientific documentation of all commercially available products within this material group. MATERIALS AND METHODS: MEDLINE was searched for all clinical and laboratory studies on FRP, and papers were browsed to identify product names. Moreover, the Internet was searched to find manufacturers of FRP products. Also, several large trade exhibitions were visited to identify products and manufacturers. All papers that included any data from a clinical setting of an identifiable product were critically appraised. Each product was categorized according to the scientific clinical documentation of their intended clinical use. RESULTS: Eleven commercial products were identified. The scientific clinical documentation of these products varied markedly, but was generally poor. No randomized controlled trials have been carried out on FRPs versus, eg, conventional treatments, nor are any long-term cohort studies available. None of the products demonstrate good evidence for usage as a technical solution to permanently replace lost teeth. CONCLUSION: The use of FRP for fixed partial dentures must still be regarded as experimental.

Composite Resins↗
PubMed2006

Measuring the user acceptance of a Web-based nursing documentation system.

OBJECTIVES: The development of an ICNP web-based nursing documentation system, and its evaluation for its usability, and its user acceptance. METHODS: A web-based nursing documentation system was designed and implemented by using the Greek translation of ICNP beta 2 version nursing terminology. The system integrates the steps of nursing process for providing and documenting nursing care, while ICNP terminology is used for the description of nursing concepts. The system was evaluated by nurses in a computer laboratory. We measured the user interaction satisfaction mainly by using questionnaires and scenarios. RESULTS: The nurses who evaluated the system possessed adequate basic computer skills; but low-to-moderate experience in clinical or hospital information systems; and insufficient experience with nursing vocabularies, and especially ICNP. Overall, they were satisfied enough with the system's usability and usefulness, while the acceptance level increased as the level of their training in computers, nursing process and ICNP was also increased. The integration and use in the system of predefined, or standardized, nursing concepts and care plans seems to increase the acceptance of the documentation system and also the ICNP. CONCLUSION: The subjective satisfaction and response of the users towards the system is specified. The described system was evaluated under "laboratory conditions" and revealed some of its strong and weak points and some of the factors that influenced its success and acceptance by its users.

Diffusion of Innovation↗
PubMed1991

The sensitivity of medical diagnostic decision-support knowledge bases in delineating appropriate terms to document in the medical record.

A pertinent, legible and complete medical record facilitates good patient care. The recording of the symptoms, signs and lab findings which are relevant to a patient's condition contributes importantly to the medical record. The consideration and documentation of other disease states known to be related to the patient's primary illness provide further enhancement. We propose that developing sets of disease-specific core elements which a physician may want to document in the medical record can have many benefits. We hypothesize that for a given disease, terms with high importance (TI) and frequency (TF) in the DX-plain, QMR and Iliad knowledge bases (KBs) are terms which are used commonly in the medical record, and may be, in fact, terms which physicians would find useful to document. A study was undertaken to validate ten such sets of disease-specific core elements. For each of ten prevalent diseases, high TI and TF terms from the three KBs mentioned were pooled to derive the set of core elements. For each disease, all patient records (range 385 to 16,972) from a computerized ambulatory medical record database were searched to document the actual use by physicians of each of these core elements. A significant percentage (range 50 to 86%) of each set of core elements was confirmed as being used by the physicians. In addition, all medical concepts from a selection of full text records were identified, and an average of 65% of the concepts were found to be core elements.(ABSTRACT TRUNCATED AT 250 WORDS)

Artificial Intelligence↗
PubMed1991

Documentation of cost savings from decentralized clinical pharmacy services at a community hospital.

A pilot program designed to justify the costs of clinical pharmacy services through the use of workload documentation cards is described. At this community hospital, defining a philosophy of care was the first step in developing and implementing decentralized services. A patient-specific care model was chosen, and principles of patient-oriented service were outlined. Daily workload documentation cards were designed for recording pharmacist activities; distribution functions were noted on one side, clinical activities on the other. Direct cost savings that could be attributed to the clinical pharmacists' drug therapy recommendations were quantified and recorded on a second form. Sixty-three beds in four hospital units were chosen as sites of the pilot effort. At the end of the six-month study, an analysis of the cost-savings forms documented that clinical pharmacist activities produced an average savings of $1.49 per patient day. The break-even point at which pharmacist salary expenses would equal direct cost savings was determined to be one clinical pharmacist per 80 patient beds. A request to expand clinical services at the hospital was granted. By documenting clinical and distributive activities on a simple form and quantifying the savings associated with clinical interventions, this pilot program demonstrated the cost-effectiveness of clinical pharmacy services.

Centralized Hospital Services↗
PubMed1991

Improving accuracy in documentation of restrictive interventions by direct-care personnel.

Accurate and reliable documentation of rights restrictions is critical for evaluating a program's success against the intrusiveness of a behavioral intervention, complying with regulatory standards, and refining treatment strategies. Direct-care and ancillary staff in three cottages at a state facility for persons with mental retardation were selected to evaluate a revised documentation system, including a new form, inservice training for staff inservice, and staff feedback, that was implemented sequentially across cottages. Results showed an immediate and sustained reduction in documentation errors following the implementation of the documentation system. Benefits and limitations of the new system were discussed.

Adult↗
PubMed1990

General form for requesting hospital documents. Part one.

As a Testifying Expert (TE), you will not speak to the documents outlined above because they involve medical, rather than nursing, issues. As a Purely Consulting Expert (PCE), you will advise plaintiff attorneys to obtain these documents in cases where applicable. You may also review these documents for either plaintiff or defense attorneys. Regardless of your role as a legal nurse consultant, you must be aware of the documents available to the attorney and how to obtain them when appropriate.

Consultants↗
PubMed1990

Standardized nursing care plans for acute care SCI: improved documentation.

Adequate documentation of spinal cord injury (SCI) nursing care is necessary for evaluation of patient progress and compliance with standards of care. The objective criteria used to evaluate nursing care include the nursing data base, the care plan, and the nurses' notes. The nursing care plan reflects the needs of the SCI client and is the basis from which documentation about these needs arises. Standards for acute care SCI nursing were recently developed for the 10 designated SCI centers in Florida. To improve the documentation of these standards, neuroscience nurses at Shands Hospital developed standardized care plans that can be individualized for each SCI client. The implementation of these care plans improved documentation of the standards for acute care SCI nursing. Additional benefits included an increased awareness of the nursing diagnoses among staff nurses and improved equality of care for the SCI client.

Documentation↗
PubMed1987

Comparison of medical, surgical and oncology patients' descriptions of pain and nurses' documentation of pain assessments.

Eighty-four nurse-patient dyads were studied to obtain descriptions of pain from medical, surgical and oncology patients experiencing pain. These descriptions were compared with the documentation of pain assessment recorded by the nurses providing care to these patients. Neither the descriptions of pain nor the amount of information documented about that pain differed significantly across the three groups. For each group, nurses documented significantly less than 50% of what the patients described. Inadequate documentation of pain assessment has legal and continuity of patient care implications.

Adult↗
PubMed1989

[Dynamics of the flow of Soviet scientific documents in social hygiene and public health organization].

In order to study the rates of accumulating new information on selected trends in social hygiene and public health organisation and in this branch of science as a whole, to explore the possibility of prognostic estimate of research efforts distribution, the dynamics of national documentation flows in this branch was analysed in 1975-1976 (959 publications), 1980-1981 (1740 publication) and 1985-1986 (2353 publications). A total of 5052 documents was studied. The study revealed that a quantitative analysis of research documentation flows reflects the intensity of accumulating the information. During last 10 years a rapid increase in the flow of publications on the problems of public health organisation was noted along with its slow progress regarding the problems of population health. The knowledge of the dynamics of documentation flow permitted to understand the nature of its further development only on the basis of large--scale major trends of the research and of the branch as a whole. It would be impossible to make similar estimations on the basis of selected specific cases of research without additional information.

Documentation↗
PubMed1989

Bar-code technology for documenting administration of large-volume intravenous solutions.

The failure to properly document dispensing, administration, charging, and crediting of large-volume plain i.v. solutions in a hospital, along with the potential for using bar-code technology to reduce documentation discrepancies, was investigated. Portable bar-code scanners and preprinted bar-code labels were employed to identify large-volume plain i.v. solutions administered on two selected nursing units of a 1000-bed, private, not-for-profit hospital. Inservice training sessions were conducted to instruct hospital personnel in the use of the scanning equipment. Comparisons of patient statements and medication administration records for large-volume plain i.v. solutions established the level of documentation errors in the study hospital. The causes of these errors were traced to three primary sources: (1) failure to document administration of a solution to a patient (38%), (2) failure to credit patients for i.v. solutions returned to the pharmacy (37%), and (3) administration of a solution to a patient other than the patient for whom the solution was dispensed (25%). Accountability for large-volume plain i.v. solution charges to patients was improved by 19% using bar-code technology. The pharmacy manager desiring to employ bar-code technology should determine convenient methods for applying bar-code labels to solutions and for scanning the bar codes, as well as provide programming that can compensate for erroneous scans.

Documentation↗
PubMed1989

Multidisciplinary approach to improving documentation of medications used during surgical procedures.

A multidisplinary approach to improving medication documentation in the operating room (OR) of a 350-bed teaching hospital is described. A committee composed of the OR pharmacy supervisor, the assistant director of nursing in charge of the ORs, and a review coordinator from the auditing department developed a medication accountability system for the OR. The system consisted of a medication use record created by the pharmacy member of the committee for each of the hospital's two ORs (main OR and eye and ear infirmary OR). The nonsterile nurse in each OR suite would complete these forms by placing check marks next to the names of the medications used. A separate medication use record was created by the chief perfusionist for use in cardiopulmonary bypass cases; this form would be completed by the perfusionist at the end of each major heart case. Once the forms were approved by the form committee, inservice-education programs were conducted for nursing and perfusion staff members; the system was implemented in both OR areas in November 1986. Errors made in completing these forms were addressed by further inservice education and individual instruction. The new accountability system was effective in improving medication documentation in the OR. Immediately after implementation of the system, 83% of medications were accounted for on the forms; after six months that figure was 90%. Before the system was implemented, only 23% of patient charts reviewed contained no errors in documentation; after six months that figure had improved to 71%. The improved medication documentation allowed for more consistent collection of the assessed pharmacy charges on bills audited by third-party payers.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1989

[Medical documentation on the accident unit at the Wels Hospital--13 years' experience].

Standardised documentation in accident surgery is to provide detailed information on surgical practice at the ward concerned, data for comparison with other hospitals, statistical documentation from which to find answers to topical questions, and material for counselling and assistance to partners. It is also intended to help in more effective economic planning. An account is given in this paper of the effectiveness of various therapeutic procedures, with reference being made to 13 years of data acquisition, using form sheet documentation of bone fractures. Reference is also made to postoperative infections, image documentation, and on some therapeutic techniques.

Documentation↗