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PubMedDate not supplied

A model of computer documentation of hospital specialty rotations.

The importance of a comprehensive documentation system for assisting residents in securing hospital privileges has been widely asserted. Other applications of a documentation system such as encouraging research, providing individual resident evaluations, and providing program evaluation are also worthy reasons for developing a system. This paper describes a computerized system for documenting the inpatient rotation experiences of family practice residents and discusses its potential applications. An example of curriculum evaluation as a use of a documentation system is detailed.

Computer Systems↗
PubMed1986

Computerized documentation of scoliosis.

The authors report their experience in the development of a computerized recording system in their scoliosis unit. The form of documentation used must be designed to comply with the memory of the available computer. Following a detailed analysis of the various fields comprising the documentation proforma, the technical methods used to minimise errors while loading the maximum number of cases into the computer are discussed. Complex statistical analyses are possible only with the aid of computerized documentation and it is hoped this will be used more frequently in future in departments specialising in the problems of vertebral deformity. The formulation of a common documentation proforma for scoliosis would unify the terminology, and make it possible to introduce comparability and homogeneity into the clinical data as well as the results of different techniques.

Computers↗
PubMed1985

Documentation of hospice care plan development and team meetings.

The interdisciplinary team meeting documentation system as described in this article meets the documentation requirements specified by JCAH and Medicare. The goal of the system is to provide necessary documentation in a format that is easy to use. Because of the generic content and format of this system, hospices in any setting or from any provider can adapt the forms to their particular needs. Delaware Hospice has shared this documentation system together with the interdisciplinary care plan form with numerous hospices who have also found them practical and instrumental in providing high-quality patient care.

Delaware↗
PubMed1982

Documented effectiveness of clinical pharmacy services.

Articles documenting the effectiveness of clinical pharmacy services were reviewed and categorized. A list of articles describing clinical pharmacy services published in the primary pharmacy literature or presented at ASHP Midyear Clinical Meetings was prepared. Selected articles were evaluated further for documented evidence of the impact of these services on patient care. Impact was defined as any one of the following outcomes: decreased morbidity (side effects, toxicity, or adverse drug reactions), decreased mortality, improved prescribing or monitoring practices, improved therapeutic outcome, and increased compliance. Ongoing clinical pharmacy services were described in 144 meeting abstracts and 117 published papers. Of the 33 papers suitable for further review, 16 provided documentation of probable or definite impact on patient care as a result of clinical pharmacy services. Three types of clinical services were provided: patient education and counseling, pharmacokinetic monitoring, and clinical drug monitoring and information. Nine studies involved ambulatory patients; eight of these involved adult patients, while one used pediatric patients. Seven of the nine studies demonstrated increased compliance through patient education and counseling. Seven studies involved adult hospitalized patients. More well-designed studies documenting the effects of clinical pharmacy services on patient outcome are needed.

Documentation↗
PubMed1978

Documentation: the first step in laboratory management.

This article will try to point out an often over-looked tool of management that most laboratory technologists are familiar with. The laboratory technologists that suddenly find themselves as chief technologists or managers would do well to remember their bench training. Specifically, document everything you do. The article lists suggestions and examples pertaining to documentation, that chief technologists could well benefit from. Four specific examples of documentation forms are as follows, (1) Pre-employment evaluation interview, (2) Laboratory orientation check list, (3) Documentation of employee counseling, and (4) Report of corrective interview.

Counseling↗
PubMed1995

[Batch documentation of blood products].

BACKGROUND: In former years transmission of infectious diseases by blood products was repeatedly observed. To trace these incriminated batches of blood products proved to be nearly impossible. METHODS: This publication describes the documentation of different batches of blood products. In the simpliest case the batch numbers of blood products can be stored in files using forms. Besides this documentation of batches can be aided by EDP using databases and barcodes. A test for the correct and complete input of data is given. RESULTS: The registration of batches of commercially available blood products as well as blood preserves is possible. Incriminated batches can be traced back. CONCLUSIONS: Besides donor selection, control of the manufacturing process and the use of inactivation procedures for viruses the documentation of batches substantially contributes to the safety of plasma derivatives. With the applied techniques documentation is easily achieved.

Blood Component Transfusion↗
PubMed1995

A comprehensive pediatric bone marrow transplant documentation tool.

PURPOSE/OBJECTIVES: To describe the development and use of a tool to document assessment and provision of education to children undergoing bone marrow transplantation (BMT) and their families. DATA SOURCES: A hospital's BMT Clinical Issues Committee, BMT staff, and hospital standards. DATA SYNTHESIS: A comprehensive tool was developed to complement the hospital's admission tool to facilitate assessment and documentation of BMT-specific education of the patient and family. The implementation of the tool was specifically designed to facilitate its use across outpatient and inpatient settings. CONCLUSIONS: Based on quality assurance indicators, the tool has succeeded in documenting appropriate education activities. IMPLICATIONS FOR NURSING PRACTICE: A consistent and organized approach to documentation is beneficial to nursing practice. This tool can be adapted to any clinical situation where educational needs are great.

Bone Marrow Transplantation↗
PubMed1994

Document needs in a rural GRATEFUL MED outreach project.

An analysis of documents provided to eight rural Illinois hospital sites during a GRATEFUL MED outreach project involving end-user searching revealed significant patterns that have implications for collection development and information services in small, underserved hospitals. Document requests were analyzed by user groups making the requests, subject matter, inclusion on the Brandon/Hill lists and in Abridged Index Medicus, and publication date. Of the 359 documents requested, 86% came from health professional groups other than physicians and nurses. Eighty-five percent of all requests came from two sites that had active project-trained intermediaries, with most requests forwarded by the intermediaries. Subject analysis revealed a strong need for administrative and allied health information in addition to clinical information. Fewer than half of the titles on the recommended lists were requested during the project. Most documents requested had been published in the past five years. Introduction of end-user searching is not the complete answer to improved information access at small hospitals; the authors conclude that basic collections and library personnel are still needed locally to respond effectively to health professionals' information needs.

Documentation↗
PubMed1993

Disclosure documents and informed consent: the pros and cons.

This article critically examines the nature, scope, role and function as well as the pros and cons of disclosure documents as a means of procuring a patient's informed consent to proposed medical intervention. The conclusion reached is that, although the disadvantages of disclosure documents outnumber and outweigh their benefits, they should not be denied a role and function. Disclosure documents may be useful instruments for furnishing the basic information that a prudent patient would require to come to a decision whether to undergo or refuse the proposed medical intervention, but individual disclosure tailored to fit the actual circumstances of the particular patient can only be achieved by means of a disclosure conversation between doctor and patient. Hence, disclosure documents may serve as a supplement to but not as a substitute for a disclosure conversation.

Documentation↗
PubMed1993

[Prospective hospital documentation as an instrument of surgical quality assurance].

UNLABELLED: In this study expenditure and benefits of a differentiated internal hospital documentation were analyzed. We particularly wanted to find out whether an independent prospective documentation of all postoperative complications has a reducing effect on the frequency of these events and therefore can be used as a means of control. METHOD: In the time between May 1989 and September 1992 the data of 8682 patients of our hospital were documented. Scientific assistants who regularly visited every ward registered every course of treatment. All data were coded and simultaneously checked. RESULTS: We found the risk of postoperative pneumonia (3.6%) especially high in units for vascular surgery and in the intensive care unit. Wound infections (5.2%) were mostly seen after transplantations and vascular surgery. Specific complications after operations showed an accumulation in certain wards. If we look at the progress since 1979 we can perceive a significant regression in the rate of wound infections and pneumonia and a constant rate of clinical lethality. In elective bowel-resections a significant reduction of wound infections and leakages could be recorded. Concerning the patient's characteristics we saw apart from a general increase in the number of operations a clear increase of endoscopic performances. CONCLUSION: Hospital documentation can uncover internal correlations and thus takes part in clinical quality assurance. Helpful are evaluations of each specific ward and the specific operations. Basis for this is the selection of suitable data and their independent evaluation. Measures of external quality assurance have not yet solved these problems convincingly.

Adolescent↗
PubMed1993

[Documentation of psychopathologic findings: a procedure for the evaluation of psychological disorders in children and adolescents].

A standardized documentation system for psychopathological findings allowing an assessment of psychiatric disorders in children and adolescents after clinical evaluation of the patient and his or her caregivers is presented. The symptomatology during the previous few months and the symptoms seen during the examination are rated separately. Altogether 113 items in 16 areas are assessed. In addition, motivation to participate in treatment is judged and a global assessment is made of symptom severity. A number of facilities are already employing this documentation system in their routine clinical work. In a first study 597 patients from a routine clinical population seen consecutively were assessed at the start of treatment. As expected, the most commonly recorded symptoms were those of expansive behavior. Such symptoms were seen much more rarely during the evaluation than outside this situation. The documentation system for psychopathological findings complements diagnosis by category according to ICD with a phenomenological description of psychiatric disturbances on the level of single symptoms. It enables simple and economical documentation of clinical findings after evaluation of the patient and his or her caregivers.

Adolescent↗
PubMed1993

Validity of immunization documentation presented to a student health program.

BACKGROUND: Unavoidable exposure to disease and to patients susceptible and vulnerable to disease warrants that students entering medical school be immunized against many of the illnesses for which vaccines are available. The validity of immunization records presented at the time of registration, however, is largely dependent on the provision of accurate and reliable documentation by the student. METHODS: We evaluated for authenticity the immunization and tuberculin testing records of 85 students entering medical school in 1990. Five levels of valid documentation were defined, and the information on each record was reviewed accordingly. RESULTS: Only 43% of the records were original documents or laboratory reports of antibody titers, and 7.5% were not date-specific. We found that 8% to 20% of the forms were missing physician and/or student signatures, and 12% to 19% of the forms did not have health care provider addresses. CONCLUSIONS: Even though medical student preventive health programs may have strict requirements, there may be substantial deficiencies in the quality of the documentation provided by the students. Such deficiencies undermine the purpose of these programs.

Adult↗
PubMed1993

[Pain assessment and documentation in patients with tumors: theory and reality].

Each tumor patient with pain is not only entitled to a careful diagnostic workup and to effective treatment of his pain syndrome, but also to a clear and useful documentation of the course of his pain(s). This documentation ('pain evolution chart') should at least include the main location(s) of the treated pain and the varying pain intensity during the course of the day as well as at night. A respective pain documentation instrument, the St. Gallen Pain Evolution Chart (S-PEC), was presented as a practical example, together with a brief review of the literature. The 'pain evolution chart' should be a regular part of the patient's hospital chart, as it forces the patient and his care-givers to cope more constructively with the present pain syndrome. The (well instructed) patient himself is responsible for an accurate and realistic pain documentation. Such longitudinal 'pain evolution charts' are not only useful for clinical oncology practice but also for clinical pain and analgesic research.

Analgesia↗
PubMed1996

[Concise International Chemical Assessment Document (CICAD): a new chemical safety series in IPCS, internationalizing national reviews].

The Concise International Chemical Assessment Document or CICAD is a new chemical safety document series. It was launched by the IPCS in 1995, based on the decision of the International Forum on Chemical Safety in 1994, to internationally assess safety of 500 additional chemicals by the year 2000. The strategy to achieve this ambitious goal is to internationalize existing national assessment documents by rearranging contents of them into a standardized format, succinctly describing critical data, and adding international assessment process so as to be prepared efficiently, concisely and reliably. Critical review of document drafts by competent experts and input from countries including developing ones is required in the preparation. The author wishes to establish a framework to develop national reviews of chemical risk assessment domestically, while cooperating with this international programme.

Computer Communication Networks↗
PubMed1997

[A new documentation system to simplify a patient-centered nursing process in ambulatory care and in long-term care in a nursing facility].

In 1995/96, the new care insurance was introduced in Germany, regulating longterm nursing care in the community and in nursing homes. In order to implement the new legislative regulations the Federal Ministry of Labour and Social Affairs commissioned the AKI Institute to develop adequate patient centered quality standards for care planning and documentation. On the results of a multimethod survey a new documentation system was developed that enables a new patient centred approach, putting the client's habits and his or her view of health problems in the centre of nursing action. Traditional formats were altered to facilitate the documentation of the nursing process. The results show clearly that care is now more orientated towards a patient's autonomy and wishes. On the whole, the documentation is clearer and more systematic.

Ambulatory Care↗
PubMed1998

Evaluation of online documentation.

The University of Iowa Hospitals and Clinics (UIHC) implemented an online documentation system for patient care orders in 1994-1996. Developed entirely in-house, the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System) features order-generated task lists, defaulted charting responses, computer-generated chart forms, and graphical data displays. To measure the impact of automation on user perceptions, and documentation compliance, completeness, time, and location, a team of nursing and information systems representatives captured data before and after implementation. Staff surveys show more positive user perceptions. Documentation results indicate increased compliance and completeness, and a decrease or no change in time. Online documentation occurs mainly at unit workstations.

Attitude of Health Personnel↗
PubMed2001

Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experienced abusive head trauma.

OBJECTIVE: To describe the clinical use of a wide-field digital ophthalmic camera (RetCam 120; Massie Research Laboratories, Inc, Dublin, Calif) for the documentation of retinal hemorrhages in patients who experienced abusive head trauma. DESIGN: Case series. SETTING: Pediatric intensive care unit at a tertiary care center. PARTICIPANTS: Children with suspected abusive head trauma. RESULTS: Eight children were studied during a 9-month period. The median age of the children was 2.25 months (range, 0.8-18.0 months). There were 4 male and 4 female patients. All patients had intracranial bleeding, documented by computed axial tomographic scans of the head. Of the 8 patients, 6 had bilateral retinal hemorrhages. All patients underwent a formal examination by a pediatric ophthalmologist (R.S. and others) using a wide-field digital ophthalmic camera. Three children died. CONCLUSIONS: The wide-field digital ophthalmic camera allowed good visualization and produced high-quality photographic images, resulting in instant bedside documentation of retinal pathological features. The wide-field digital ophthalmic camera provides a new tool for the evaluation and precise documentation of retinal hemorrhages in suspected and confirmed cases of abusive head trauma.

Child Abuse↗
PubMed1998

A DICOM document-oriented approach to PACS infrastructure.

The need for long-term storage requires the future migration of image data from a PACS to its successor system. This paper considers the cost of such migration It is proposed that storage of data as "documents" in DICOM Part 10 formats on industry-standard media could reduce the time and cost of data migration relative to on-line DICOM transfer. The relation to present efforts in developing document-oriented electronic patient records is discussed. DICOM Part 10 files are found to be a sufficient representation of image documents, but additional software tools will be needed to reach its full potential. There is a significant cost benefit of the document storage method, but it is one of many factors which must be balanced in the selection of a PACS.

Costs and Cost Analysis↗