SEARCH · Search PubMed

Results for “Records”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

SourceResearch connectionFrom yearThrough year

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 631 records · Page 35Linked to original sources

PubMed2003

The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.

BACKGROUND: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. AIM: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. DESIGN OF STUDY: Retrospective cohort study. SETTING: Eighteen general practices in the Exeter Primary Care Trust. METHOD: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, depending on which medium stored the clinical information from consultations. RESULTS: More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P <0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems. CONCLUSION: Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.

Aged↗

PubMed1988

Human electrogastrograms: comparison of techniques of recording.

There are different methods for recording physiologic electrical signals cutaneously. Monopolar recording has been used, by us and by others, to record the basic electrical rhythm of the stomach. In an effort to improve our ability to routinely obtain a recording of the basic electrical rhythm of the stomach, using cutaneous electrodes (electrogastrography), we have investigated different electrode recording techniques, and compared them with monopolar recording. We studied 10 healthy asymptomatic volunteers who were fasting, using each of the techniques while simultaneously monitoring a monopolar electrogastrogram. Three different recording techniques were studied: a Wilson central terminal, comparing alternative placements of the reference electrodes; a Wilson central terminal with a single placement of the reference electrodes, but alternative placements of the active exploratory electrode; and, last, a differential recording technique. We found all of the studied techniques to be superior to monopolar recording in the amount of time a recognizable three/min basic electrical rhythm could be recorded. However, the differential recording arrangement yielded an improvement in percent of recording time so significant that the electrogastrographic signal could be visually discerned to greater than 80%, compared with 37%, of the monopolar recording. Thus, the differential recording technique is far superior for recording the electrogastrogram.

Electrodes↗

PubMed2001

Concordance of information in parallel electronic and paper based patient records.

OBJECTIVE: to evaluate the results of parallel use of both paper based and electronic patient records with respect to concordance of corresponding information in two continuously updated versions of the same records. DESIGN: retrospective evaluation of patient records, comparing documentation in electronic and paper based patient records. SETTING: Department of Neurology in a Norwegian university hospital using paper based and electronic patient records in parallel during migration towards completely electronic patient records. MATERIAL: electronic and paper based patient records of 90 randomly selected patients visiting the department between 1 November 1997 and 30 April 1999. RESULTS: seven percent of the electronic documents were significantly different in some way from the corresponding paper documents. About 4-13% of the documents in the electronic record were missing; one percent were missing from the paper record. CONCLUSION: parallel use of electronic and paper based patient records has resulted in inconsistencies between the record systems in our setting. Documentation is missing in both the electronic and paperbased records. When implementing electronic record systems intended to operate in parallel with paperbased systems, focus should be on securing the validity of all versions of the record.

Chi-Square Distribution↗

PubMed2000

Arterial blood pressure and heart rate discrepancies between handwritten and computerized anesthesia records.

UNLABELLED: Previous publications suggest that handwritten anesthesia records are less accurate when compared with computer-generated records, but these studies were limited by small sample size, unblinded study design, and unpaired statistical comparisons. Eighty-one pairs of handwritten and computer-generated neurosurgical anesthesia records were retrospectively compared by using a matched sample design. Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and heart rate (HR) data for each 5-min interval were transcribed from handwritten records. In computerized records, the median of up to 20 values was calculated for SAP, DAP, and HR for each consecutive 5-min epoch. The peak, trough, standard deviation, median, and absolute value of the fractional rate of change between adjacent 5-min epochs were calculated for each case. Pairwise comparisons were performed by using Wilcoxon tests. For SAP, DAP, and HR, the handwritten record peak, standard deviation, and fractional rate of change were less than, and the trough and median were larger than, those in corresponding computer records (all with P: < 0.05, except DAP median and HR peak). Considering together all the recorded measurements from all cases, extreme values were recorded more frequently in computerized records than in the handwritten records. IMPLICATIONS: The discrepancies between handwritten and computerized anesthesia records suggest that some of the data in handwritten records are inaccurate. The potential for inaccuracy should be considered when handwritten records are used as source material for research, quality assurance, and medicolegal purposes.

Adolescent↗

PubMed2000

The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards.

AIMS: Accurate recording of medication histories in hospital medical records (HMR) is important when patients are admitted to the hospital. Lack of registration of drugs can lead to unintended discontinuation of drugs and failure to detect drug related problems. We investigated the comprehensiveness of medication histories in HMR with regard to prescription drugs by comparing the registration of drugs in HMR with computerized pharmacy records obtained from the community pharmacy. METHODS: Patients admitted to the general ward of two acute care hospitals were included in the study after obtaining informed consent. We conducted an interview on drugs used just prior to hospitalization and extracted the medication history from the HMR. Pharmacy records were collected from the community pharmacists over a 1 year period before the admission. Drugs in the pharmacy records were defined as possibly used (PU-drugs) when they were dispensed before the admission date and had a theoretical enddate of 7 days before the admission date or later. If any PU-drug was not recorded in the HMR, we asked the patient whether they were using that drug or not. RESULTS: Data were obtained from 304 patients who had an average age of 71 (range 40-92) years. The total number of drugs according to the HMR was 1239, 43 of which were not used. When compared with the pharmacy records we found an extra 518 drugs that were not recorded in the HMR but were possibly in use. After verification with the patients, 410 of these were indeed in use bringing the total number of drugs in use to 1606. The type of drugs in use but not recorded in the HMR covered a broad spectrum and included many drugs considered to be important such as cardiovascular drugs (n = 67) and NSAIDs (n = 31). The percentages of patients with 0, 1, 2, 3, 4, 5-11 drugs not recorded in the HMR were 39, 28, 16, 8, 3.6 and 5.5, respectively. Of the 1606 drugs in use according to information from all sources, only 38 (2.4%) were not retrievable in the pharmacy records when the complete year prior to hospitalization was evaluated. CONCLUSIONS: The medication history in the hospital medical record is often incomplete, as 25% of the prescription drugs in use is not recorded and 61% of all patients has one of more drugs not registered. Pharmacy records from the community pharmacist can be used to obtain more complete information on the medication history of patients admitted to the hospital.

Adult↗

PubMed1998

Relationship between practice organization and cardiovascular risk factor recording in general practice.

BACKGROUND: Research findings suggest that the level of cardiovascular risk factor recording in general practice is not yet optimal. Several studies indicate a relation between the organization of cardiovascular disease prevention at practice level and cardiovascular risk factor recording. AIM: To explore the relation between the organization of cardiovascular disease prevention and risk factor recording in general practice. METHOD: A cross-sectional study was conducted using data on adherence to selected practice guidelines and on cardiovascular risk factor recording from 95 general practices. Practice guidelines were developed beforehand in a consensus procedure. Adherence was assessed by means of a questionnaire and practice observations. Risk factor recording was assessed by an audit of 50 medical records per practice. RESULTS: Factor analysis of risk factor recording revealed three dimensions explaining 76% of the variance: recording of health-related behaviour, recording of clinical parameters, and recording of medical background parameters. Adherence to the guideline 'proactively invite patients to attend for assessment of cardiovascular risk' was related to a higher recording level in all three dimensions. Practice characteristics did not show a consistent relationship to the level of risk factor recording. CONCLUSION: This study indicates that the presence of a system of proactive invitation was related to the recording of cardiovascular risk factors in medical records in general practice.

Adult↗

PubMed1978

Comparison of the human evoked electrospinogram recorded from the intrathecal, epidural and cutaneous levels.

In 30 patients (17 of whom had a clinically normal spinal cord) spinal cord potentials evoked by peripheral nerve stimulation were studied with computer averaging techniques in order to compare the intrathecal, epidural and skin records. In epidural and skin records, segmental spinal cord potentials either recorded from lower cervical or lower thoracic intervertebral levels often had similar shapes and latencies, especially with regard to the first component of the intrathecally recorded responses. The second slow component became less significant and was even absent in some cases. The amplitude of the first component was on average 33% of that recorded intrathecally when recorded epidurally and only 10% when recorded from the skin. In three cases potentials of very prolonged onset latency were recorded epidurally or cutaneously while in the same cases intrathecal records resulted in potentials with normal latencies. Cervical tract responses at the C6--7 intervertebral level after stimulation of the posterior tibial nerve were studied by the 3 recording methods. Epidural and skin records failed to reveal such a response regularly, while intrathecal recording invariably provided the cervical tract response. The 3 recording methods were discussed with respect to clinical applications and research. It can be stated with some reservation that epidural and skin surface recording techniques could be exploited it one could know the time of arrival segmental afferent inputs at the spinal cord.

Adolescent↗

PubMed1992

Membrane properties of dentate gyrus granule cells: comparison of sharp microelectrode and whole-cell recordings.

1. Whole-cell and sharp electrode recordings from adult rat dentate gyrus GCs were performed in the 400-microns-thick hippocampal slice preparation maintained at 34 +/- 1 degrees C. Intrinsic membrane properties of granule cells (GCs) were evaluated with the use of a switching current-clamp amplifier. 2. With the whole-cell technique, the average resting membrane potential (RMP) of GCs was -85 mV when a potassium gluconate electrode solution was used versus -74 mV measured with potassium acetate-filled sharp microelectrodes. The membrane voltage response to injected current was linear over two membrane potential ranges, greater than 10 mV hyperpolarized from RMP and between 10 mV more negative than RMP and -62 mV. The average input resistances (RN) calculated over these ranges were 107 and 228 M omega in the whole-cell recordings versus 37 and 54 M omega in the sharp electrode recordings. There was no correlation between RMP and RN with either recording technique. The membrane time constant (tau m) determined at the RMP was 26.9 ms for whole-cell recordings and 13.9 ms for sharp electrode recordings. 3. There was no evidence of time-dependent changes in RMP, RN, and tau m in whole-cell recordings, although the slow inward rectification seen at hyperpolarized potentials decreased over 30-60 min. Addition of calcium buffers to the whole-cell recording solution did not result in a significant change in the average RMP, the average RN, or the average tau m. 4. Action potential threshold was comparable in whole-cell (-49 mV) and sharp electrode (-52 mV) recordings, but action potential amplitude was larger in whole-cell (126 mV) than in sharp electrode (106 mV) recordings. Spike frequency adaptation was present in the whole-cell recordings and could be abolished by addition of calcium buffers to the electrode solution. 5. We estimated rho, the ratio of dendritic to somatic conductance, to be 5.1 for the whole-cell records and 2.1 for sharp electrode recordings. The electrotonic length of the equivalent cylinder representing the cell processes was estimated to be 0.49 from the whole-cell data and 0.79 from the sharp electrode recordings. This implies that at rest there is only a 10% decrement in steady-state membrane voltage along the length of the dendrite due to shunting across the membrane resistance; small synaptic events occurring in the distal dendritic tree will therefore have a more substantial influence on the soma than previous analyses suggested.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed2000

Assessment of reporting and recording system of communicable diseases in Jeddah Region.

OBJECTIVE: To determine the rate of reporting communicable diseases in Jeddah region, and to compare the recording system between the governmental and private sector. METHODS: This is a review of records study, in which the reports of communicable diseases from all hospitals and health centers (with or without cases) were studied, during the period of study; 1st to 25th international weeks 1999, and the reporting rate was calculated. A simple random sample was collected from these international weeks to evaluate the quality of recorded information. RESULTS: The reporting rate was 74%. Private hospitals have the highest rate in reporting (87%) and polyclinics have the least (67%). The recording rate was above 90% for administrative data. Personal data was complete except for patient name (76.5%), address (20%), and occupation (73%). The most prominent defect in the disease data was found to be in recording the mode of infection (13%), followed by previous vaccination (29%), date of symptoms (89%), and date of diagnosis (98%). Mode of infection was recorded in (40.5%) of cases by primary health care centers, but in polyclinics in only 1% of cases. Previous vaccination was recorded better by governmental sectors; (29%) by governmental hospital and (49%) by primary health care centers while in the private sectors the rate was (21%) by polyclinic and (25%) by private hospital. Date of symptoms was recorded in 90% of cases in all sectors except in governmental hospitals where it was only (50%). Date of diagnosis was recorded in more than (95%) in all sectors. The results show a statistical significant difference between different health sectors in recording data where government hospitals were least in recording doctor's name and in putting an official stamp in the form (p< 0.001); primary health care centers were the best in recording patient name and occupation (p< 0.001); polyclinics were least in recording mode of infection and previous vaccination (p< 0.001); for recording date of symptoms private hospitals were the best (p< 0.001). CONCLUSION: The reporting rate in Jeddah region was 74%, but its usefulness was diminished because of the incomplete, absent or incorrect personal and disease data.

Ambulatory Care Facilities↗

PubMed2006

Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record.

OBJECTIVE: The aim of the study was to describe a paper-based, template-driven and an electronic medical record used for capturing emergency care clinical information and to compare the accuracy of these documentation systems for coding patient encounters using the American Medical Association Current Procedural Terminology-2004 (AMA CPT-2004) evaluation and management codes intended for provider reimbursement. METHODS: A retrospective, cross-sectional study of 4-consecutive-day samples of ED patient encounter records from 2 similar community hospitals was done. For clinical documentation, hospital A uses an electronic medical record, whereas hospital B uses a paper-based template-driven record. Using a simple analytic model, expert coders A and B, respectively, coded the records from hospitals A and B for completeness. First, power analysis determined the acceptability of the patient record sample sizes (1 - beta = .90 at 1% significance level), and the frequency of AMA CPT-2004 primary evaluation and management codes 99281 through 99285 was calculated. Second, the completeness discrepancy rates for hospitals A and B were compared to determine the accuracy of both the paper-based, template-driven record and the electronic medical record in documenting and representing the clinical encounter. Third, interrater reliability between expert coders A and B was calculated to assess the level of agreement between each expert coder in determining the completeness discrepancy rates between hospitals A and B. Finally, the frequency of primary evaluation and management codes was analyzed to determine if there was a statistically significant difference between the paper-based, template-driven record and the electronic medical record representation of the clinical information, and if that difference could be attributable to the differing clinical documentation systems used in hospitals A and B. RESULTS: First, descriptive display demonstrated a difference in the frequency of the primary evaluation and management codes 99283 and 99284 within hospital A (expert coder A assessment, 36.1% vs 39.1%; expert coder B assessment, 36.6% vs 38.7%) and hospital B (expert coder A assessment, 47.8% vs 21.9%; expert coder B assessment, 48.6% vs 21.4%) was noted with the median, primary evaluation, and management code for hospital A of 99284 and the median, primary evaluation, and management code for hospital B of 99283. Second, Fisher exact test compared the completeness discrepancy rates between hospitals A and B as assessed by each expert coder and demonstrated no statistically significant difference in the completeness discrepancy rates (accuracy) between the paper-based, template-driven record and the electronic medical record documentation and coding system when assessed by either expert coder A (P = .370) or expert coder B (P = .819). Third, interrater reliability between expert coders A and B was evaluated using Cohen's kappa statistic. When evaluated both individually and jointly with respect to hospitals A and B, expert coders A and B had a good strength of agreement in their assessments of the accuracy of the documentation and coding system for hospital A (kappa = 0.6200) and hospital B (kappa = 0.6906) as well as for both hospitals evaluated together (kappa = 0.6616). Finally, interhospital differences in the frequency of primary evaluation and management codes were evaluated using Pearson chi(2) test with 3 df. The results for expert coder A (chi(2) = 47.4160; P < .001) and expert coder B (chi(2) = 46.5946; P < .001) recognize that there is a statistically significant degree of difference between hospitals A and B in the frequency distribution of primary evaluation and management codes, probably because of the dispersion of codes 99283 and 99284. CONCLUSIONS: A keystroke-driven, electronic medical record that resides on a knowledge platform that incorporates a clinical structured terminology, administrative coding schemata, AMA CPT-2004 codes and uses object-oriented, open-ended, branching chain clinical algorithms that "force" physician documentation of the clinical elements provides an equally accurate capture and representation of ED clinical encounter data as a paper-based, template-driven documentation system both in terms of the presence or absence of both the medically necessary, discrete data elements and the textual documentation-dependent, medical decision-making elements.

Chi-Square Distribution↗

PubMed1990

Pilot study of records of shared care for people with mental illnesses.

OBJECTIVE: To develop and evaluate a record of shared care to be held by the patient designed to increase the effectiveness of long term care of patients with severe mental illness. DESIGN: Questionnaires completed by medical staff, community psychiatric nurse, and patients to evaluate the shared care record. SETTING: General practices, a psychiatric outpatient clinic, and a mental health resource centre in south east London. PATIENTS: 84 Patients held shared care records over an 18 month period. They were selected by general practitioners, a psychiatrist, or a community psychiatric nurse, the criterion being that their care was shared between the general practitioner and the psychiatrist or community psychiatric nurse. Patients who had been admitted to hospital several times with short remissions were excluded. MAIN OUTCOME MEASURES: Patients were asked to complete a questionnaire to assess their views on the acceptability, usefulness, and problems of the shared care record. A questionnaire for health staff was designed to identify patients for whom the shared care record was most and least appropriate. It also assessed the patients' compliance and the way the record affected communication between all concerned. RESULTS: Patients found the shared care records very acceptable and were enthusiastic about their use. They valued being consulted about what was recorded and found the record of their treatment and progress useful. Patients also thought that they were in a better position to challenge their doctor. Those least likely to comply were people with severe paranoia. The acceptability of the record to patients greatly exceeded that to the psychiatrists and nurse managers, none of whom were interested in using the record. Communication among health staff was greatly improved by the shared care record, and it facilitated the identification of potentially dangerous drug interactions. CONCLUSIONS: Shared care records were acceptable to patients with severe mental illnesses, increased the patients' autonomy, and improved communication and the effectiveness of shared care. Obstacles to further development of this approach relate to the attitudes, perceptions, and anxieties of the doctors, nurses, and managers and can be overcome.

Attitude to Health↗

PubMed1998

A comparison of ambulatory Medicaid claims to medical records: a reliability assessment.

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

Adult↗

PubMed1998

Issues in identification and linkage of patient records across an integrated delivery system.

Historically, the health information systems community has viewed linking personal records as a mundane task. The oversimplified view that routine database manipulation can accurately identify multiple records for a single individual is erroneous, an assumption based on a misperception of the quality of the underlying data. Such data have been adversely affected by the evolution of individual facility patient indexes from multiple systems and the results of backload procedures, and the lack of focus on the need for data integrity by users of the automated systems. Much of the random, invalid data we identify on a daily basis is directly associated with the need for system users to place data in the patient record while they face the situation of having no obvious data field in which to place them. Combined with an underlying lack of standards for the collection of personal identification information, this results in pure chaos when reviewing an MPI file containing a million records at the start of a linkage evaluation project. We have documented the considerable effort that must therefore be made in standardizing the MPI files using stringent analytical procedures and applying common edit routines before commencing record linkage. This preprocessing effort must then be supplemented with sophisticated matching procedures that can handle the dual challenge of minimizing false negatives (the failure to identify true linkages) and false positives (the incorrect linking of records that do not represent the same person). The identification of pairs of linked records does not, however, complete an EPI loading. Because it is fairly common for a multiple facility linkage evaluation to identify more than two medical record numbers for the same patient, and the primary goal of an EPI is to assign a unique identifier for the patient which will link that patient's multiple files, it becomes necessary to develop a means of readily associating three or more records for the same patient. One approach we have used with great success is to assign a common, sequential identification number to all linked medical record numbers for the same patient regardless of facility. The assignment of linkage identification numbers is computer-intensive and is generally accomplished with a highly iterative process. Both system memory and hard disk resources are fully tested as the number of good linkages in an overlap evaluation reaches the half-million mark or greater. Because the primary linkage analysis goal is to develop linkages on pairs of records, with confidence levels based on the comparison of information for those two records, thresholds must be set to decide which linkages should be accepted as true without any human evaluation. If the threshold is set too low, the defined linkage groups may incorrectly join the medical record numbers for different persons. But if the threshold is set too high, there will be undesired duplication of persons in the enterprise system. As in the identification of the underlying linkage pairs, the development of a confidence measure greatly facilitates the assignment of the unique identification numbers needed in the EPI implementation.

Algorithms↗

PubMed2004

Outpatient Osteopathic Single Organ System Musculoskeletal Exam Form series: validation of the Outpatient Osteopathic SOS Musculoskeletal Exam Form, a new standardized medical record.

The authors validate the Outpatient Osteopathic SOS (Single Organ System) Musculoskeletal Exam Form (SOS MSEF), a 1-page form contained within the 4-page Outpatient Osteopathic Single Organ System Musculoskeletal Exam Form Series (SOS-FS). Handwritten physician progress notes (PPNs) in the medical record (considered to be the "gold standard" for clinical records) were compared with information placed on the SOS MSEF for the same patient encounter. Data recorded by 14 trained and certified investigators on the standardized SOS MSEF-which was designed for use with the previously validated Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form (SNF)-was compared with data recorded by the same investigators in PPNs. The authors compared the accuracy and efficiency of physicians recording musculoskeletal information in these two formats for 165 patient encounters. Descriptive statistics and t tests were used to compare data recorded after patient encounters. Ninety-seven variables input from the PPNs or SOS MSEFs were significantly different at the P < or = .05 level, whereas 38 variables were not. Insufficient data was recorded for a determination of significance in 3 variables. For 121 variables, more data were recorded using the SOS MSEFs than PPNs; for 84 variables, the amount of data recorded exceeded twice that recorded using PPNs. For 10 variables, more data were recorded in PPNs; however, these differences were not significant. The authors conclude that the SOS MSEF is superior to PPNs for recording patient-encounter data in the osteopathic care setting. Moreover, they argue that the use of the validated SOS MSEF nationwide would ensure that osteopathic physicians would be recording data in a similar manner for uniform insurance claim coding, easy tracking of physicians-in-training and patient outcomes, and data collection for future research.

Forms and Records Control↗

PubMed1991

How well are parent held records kept and completed?

During 1986 and 1987 parents in part of the Oxfordshire district health authority were given their child's health and development records while in the other part of the health district the records remained with the clinic. Between August 1988 and February 1989 an audit was made of a sample of parents attending child health clinics in the two areas: the study examined 284 parents who had parent held records and 168 who did not; how many records were available and if not, why not; how well and by whom records were completed and parents' views on who they felt should keep the record. Interviews revealed that parents with a parent held record liked the scheme and were confident about remembering to take the record to the clinic. Those without experience were less confident and more concerned about losing the record. At the time of the audit 7% of parent held records had been lost or forgotten, but 5% of clinic held records were not available for inspection. Overall, parent held records were more likely to have comments contributed by parents and to be more thoroughly completed by professionals. The results suggest that parent held records are not only workable but desirable.

Child↗

PubMed1997

Computerized data collection in the operating room during coronary artery bypass surgery: a comparison to the hand-written anesthesia record.

OBJECTIVE: To investigate variability between hand-written and computerized anesthesia records and evaluate any associated bias. DESIGN AND MEASUREMENTS: A computer system that was used to collect intraoperative data for a study of hemodynamic management during coronary artery bypass graft surgery is described. The system collected and recorded hemodynamic data automatically downloaded from the anesthesia monitor as well as surgical events and drug administration data entered through menu options. The system then combined, summarized, and graphed the data as well as formatted it for export to a commercially available database program. In a sample of 14 patients, blood pressure data collected by the computer system was compared with the blood pressure data charted in the hand-written anesthesia record. MAIN RESULTS: Although general linear models controlling for within-patient variation and randomization assignment for mean arterial pressure range on cardiopulmonary bypass showed a significant relationship; low R2 values indicated that much of the variability could not be explained and that there was, therefore, poor agreement between the two records. Furthermore, a systematic bias in the hand-written anesthesia record was found when the computer system record was compared with the hand-written record and to the difference of the two records, so that extremes seen in the computer system record tended to be minimized in the hand-written anesthesia record. CONCLUSIONS: Because of the lack of explained variability between the computer system and hand-written anesthesia records and the bias in the hand-written anesthesia record, the hand-written anesthesia record should not be relied on as a source of accurate data for research purposes.

Anesthesia↗

PubMedDate not supplied

Real-time pulse oximetry artifact annotation on computerized anaesthetic records.

OBJECTIVES: Adoption of computerised anaesthesia record keeping systems has been limited by the concern that they record artifactual data and accurate data indiscriminately. Data resulting from artifacts does not reflect the patient's true condition and presents a problem in later analysis of the record, with associated medico-legal implications. This study developed an algorithm to automatically annotate pulse oximetry artifacts and sought to evaluate the algorithm's accuracy in routine surgical procedures. METHODS: MacAnaesthetist is a semi-automatic anaesthetic record keeping system developed for the Apple Macintosh computer, which incorporated an algorithm designed to automatically detect pulse oximetry artifacts. The algorithm labeled artifactual oxygen saturation values < 90%. This was done in real-time by analyzing physiological data captured from a Datex AS/3 Anaesthesia Monitor. An observational study was conducted to evaluate the accuracy of the algorithm during routine surgical procedures (n = 20). An anaesthetic record was made by an anaesthetist using the Datex AS/3 record keeper, while a second anaesthetic record was produced in parallel using MacAnaesthetist. A copy of the Datex AS/3 record was kept for later review by a group of anaesthetists (n = 20), who judged oxygen saturation values < 90% to be either genuine or artifact. RESULTS: MacAnaesthetist correctly labeled 12 out of 13 oxygen saturations < 90% (92.3% accuracy). A post-operative review of the Datex AS/3 anaesthetic records (n = 8) by twenty anaesthetists resulted in 127 correct responses out of total of 200 (63.5% accuracy). The remaining Datex AS/3 records (n = 12) were not reviewed, as they did not contain any oxygen saturations <90%. CONCLUSIONS: The real-time artifact detection algorithm developed in this study was more accurate than anaesthetists who post-operatively reviewed records produced by an existing computerised anaesthesia record keeping system. Algorithms have the potential to more accurately identify and annotate artifacts on computerised anaesthetic records, assisting clinicians to more correctly interpret abnormal data.

Algorithms↗

PubMed1990

The accuracy of medication histories in the hospital medical records of elderly persons.

Medication histories written in medical records are important sources of information for clinicians and researchers. Medication histories in outpatient records are frequently inaccurate; the accuracy of the histories in hospital records has not previously been studied. We evaluated the accuracy of medication histories recorded in hospital medical records of 122 persons over the age of 65 at three sites, comparing the written record to a structured history obtained from the patient by the research staff. We defined an error as either the failure to record the use of a medication the patient claimed to use or the recording of a medication that the patient denied using. We found that 83% of all patients had at least one such error, and 46% had three or more. We reanalyzed the data excluding over-the-counter, tropical, and cold medications, and found that 60% of all patients still had at least one error, and 18% had three or more. Failure to record use in the record was more common than recording medications the patient denied using. There were no qualitative differences between hospitals or between the histories obtained by interns and attending physicians. This analysis suggests that medication histories in the hospital medical record are not accurate sources of information in elderly persons. Errors in the history may adversely affect clinical care; researchers relying on hospital medical records to determine medication use at the time of admission should first validate their data.

Aged↗