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PubMed1990

Physician documentation of diabetes care: use of a diabetes flow sheet and patient education clinic.

We assessed two interventions designed to improve the care of patients with diabetes mellitus by documenting the complications of their disease. These were a flow sheet, included with outpatient medical records, and a weekly patient education clinic, in which a nurse educator provided individualized instruction to patients with diabetes. Physician compliance with recommendations of the National Diabetes Advisory Board for diabetes care was measured before (n = 45) and after (n = 158) these interventions. The numbers of referrals to ophthalmologists increased from 22% to 46%, urinalyses increased from 58% to 77%, and lower extremity examinations increased from 36% to 61%. Nutrition education documentation increased from 51% to 69%, and diabetes education documentation increased from 31% to 61%. These results suggest that a significant improvement in physicians' documentation of care of patients with diabetes can be achieved by using a flow sheet and a diabetes patient education clinic.

Adult↗

PubMed2004

Documentation of posttraumatic nerve compression in patients with normal electrodiagnostic studies.

BACKGROUND: Electrodiagnostic evaluation may suggest the absence of posttraumatic nerve compression in the presence of patient symptoms. Computer-assisted neurosensory testing documents peripheral nerve sensory impairment. In the setting of trauma, where there are often legal implications, documentation of peripheral nerve compression is important. This is highlighted in the diabetic, who may have neuropathy. METHODS: A prospective study tracked trauma-related peripheral nerve problems in patients with "normal" electrodiagnostic studies, and for whom surgical care or legal outcome was determined by documentation of abnormalities by testing with the Pressure-Specified Sensory Device. Eight patients were identified, four of whom had diabetes. RESULTS: In all eight patients, neurosensory testing documented peripheral nerve problems, which was critical in obtaining approval from workers' compensation insurance carrier for decompression of the nerve and facilitating legal settlement. CONCLUSION: Neurosensory testing with the Pressure-Specified Sensory Device identifies peripheral nerve compression related to trauma, facilitating management of the patient, even in the presence of diabetic neuropathy.

Diabetic Neuropathies↗

PubMedDate not supplied

Health-related quality of life and other patient-reported outcomes in the European centralized drug regulatory process: a review of guidance documents and performed authorizations of medicinal products 1995 to 2003.

OBJECTIVES: The objective of this study was to review and analyze the use of health-related quality of life (HRQL) and other patient-reported outcome (PRO) evaluations for the approval of new pharmaceutical products by the European Medicines Agency (EMEA). METHODS: All published EMEA guidance documents and regulatory information for products authorized at the EMEA and appearing in the European Public Assessment Report (EPAR) database between 1995 and 2003 were examined for reference to HRQL and other PROs. RESULTS: More than half of the guidance documents for clinical investigation of pharmaceutical products in specific disease areas included reference to HRQL or other PROs. Guidance notes for 10 conditions indicated PROs can serve as primary endpoints in clinical trials, among which three included HRQL outcomes. The review of EPAR documentation uncovered HRQL and other PRO data for 34% of the drugs registered during the period of the review, with cancer-related treatments most frequently including PRO data. There was a trend toward increasing HRQL and other PRO claims in regulatory documents of pharmaceutical products in recent years, with the proportion exceeding 30% from 1999 to 2003. CONCLUSIONS: There is further scope for health outcomes researchers and regulatory decision-makers to contribute to the more efficient utilization of PROs and HRQL outcomes. Health researchers need to better justify the inclusion of these outcomes in clinical trials and highlight the added value of PRO data; while the regulators should develop harmonized procedures and capacities to adequately appraise the submitted information.

Chronic Disease↗

PubMed2000

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions.

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals. PATIENTS: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued. RESULTS: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn. CONCLUSIONS: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

APACHE↗

PubMed2006

Time relation between a syncopal event and documentation of atrioventricular block in patients with bifascicular block: clinical implications.

BACKGROUND: Transient high-degree atrioventricular (AV) block is a common cause of syncope in patients with bifascicular block (BFB) but the intermittent nature of AV block makes ECG documentation a challenge. A sensitive and safe tool to investigate BFB patients with syncope would be a bradycardia-detecting pacemaker, which provides a possibility of studying the time relation between the index syncopal episode and the development of high-degree AV block. METHODS: Twenty-seven patients with BFB and syncope were studied prospectively. All patients received a single-chamber ventricular-based pacemaker with bradycardia-detecting ability. A bradycardia episode was defined as a heart rate of < 30 beats/min lasting > or = 6 s. RESULTS: During a median follow-up of 60 months, a bradycardia event was detected in 14 patients (52%), of whom 13 also had documented high-degree AV block on ECG. The median time between the syncopal episode and the first pacemaker-detected bradycardia event was 5 months and after an additional median time of 6 months, high-degree AV block was documented on the ECG. In 10 of 13 patients (77%) high-degree AV block was documented within 24 months of the syncopal episode corresponding to an annual incidence of 19% during the first 2 years of follow-up in the study population. CONCLUSION: In this group of BFB patients a syncopal episode was highly predictive of the development of high-degree AV block within 24 months, justifying pacemaker therapy without prior ECG verification.

Aged↗

PubMed1984

Role of triple extrastimuli during electrophysiologic study of patients with documented sustained ventricular tachyarrhythmias.

Electrophysiologic studies were performed in 172 consecutive patients for evaluation of documented sustained ventricular tachyarrhythmias. One hundred thirteen patients presented with sustained ventricular tachycardia that was hemodynamically stable, and 59 patients presented with cardiac arrest. Seventy-one patients without previously documented or suspected ventricular arrhythmias were also studied to determine the specificity of our electrophysiologic study protocol. The stimulation protocol included single, double, and triple right ventricular extrastimuli and rapid ventricular pacing at multiple cycle lengths performed at one or more right ventricular sites. Stimulation was performed at one or more left ventricular sites in patients with documented spontaneous arrhythmias when right ventricular programmed stimulation failed to induce sustained ventricular tachycardia. Ventricular tachyarrhythmias were induced in 110 (97%) of the patients who presented with sustained ventricular tachycardia, in 48 (81%) of the patients who presented with cardiac arrest, and in 28 (40%) of the patients without documented spontaneous arrhythmias. Right ventricular triple extrastimuli induced tachycardia in 22% of patients who presented with sustained ventricular tachycardia vs 46% of those who presented with cardiac arrest (p less than .001). Left ventricular stimulation was required for tachycardia induction in 3% of patients with stable tachycardia vs 19% of those with cardiac arrest (p less than .01). Triple extrastimuli induced 57% of tachycardias in the 28 patients without spontaneous arrhythmias, and virtually all of these tachycardias were polymorphic and nonsustained. The cycle lengths of tachycardias induced in each group by double and triple extrastimuli were similar, but the tachycardias induced in patients with cardiac arrest were significantly faster than those induced in the ventricular tachycardia group (mean cycle length 218 vs 291 msec, p less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1997

Resident documentation of diagnostic impression in sexual abuse evaluations.

In sexual abuse evaluations, the documentation of the examiner's diagnostic impression is essential. If the diagnostic impression is not documented, the examiner will have to rely on memory rather than the medical record when called to testify. The purpose of this study was to determine whether pediatric residents adequately document their diagnostic impression in child sexual abuse evaluations. We performed a three-year retrospective chart review from patients 0-17 years of age who were evaluated at our emergency room for suspected sexual abuse. We reviewed 1,487 charts for historical information, physical findings, and diagnostic impression. Physical findings were categorized as normal, nonspecific, suggestive, or indicative of penetration. In 77% of cases (N = 256) with hymenal findings indicative of penetration and 84% of cases (N = 31) with vaginal findings indicative of penetration, residents recorded no impression or a nonspecific impression. Results were similar for vulvar and rectal findings indicative of penetration. Residents fail to document an adequate interpretation of their physical examinations in sexual abuse evaluations.

Adolescent↗

PubMed2001

A standardized, uniform and universal dental chart for documenting state of dentition before anaesthesia.

It is vital to have adequate and precise documentation of the condition of a patient's dentition before commencing an anaesthetic. The incidence of dental damage during anaesthesia is not low. To the authors' knowledge, there is no standardized method used by anaesthetists to document the state of a patient's dentition. We propose the introduction of a standardized uniform dental chart to enable anaesthetists to accurately document the condition of their patients' teeth. This vital information can be easily obtained during the preanaesthetic assessment. With the increase in medical litigation and demands for adequate documentation, we believe this chart can become an invaluable part of every hospital's preanaesthetic assessment form. The dental chart is to be offered as a service to anaesthetists in the form of a copyright-free "Freeware" computer diskette or adhesive sticker and will be downloadable from the internet.

Adult↗

PubMedDate not supplied

Development and validation of the international knee documentation committee subjective knee form.

A committee of international knee experts created the International Knee Documentation Committee Subjective Knee Form, which is a knee-specific, rather than a disease-specific, measure of symptoms, function, and sports activity. The purpose of this study was to evaluate the reliability and validity of the new International Knee Documentation Committee Subjective Knee Form. To provide evidence for reliability and validity, we administered the final version of the form, along with the Short Form-36, to 533 patients with a variety of knee problems. Analyses were performed to determine reliability, validity, and differential item function related to age, sex, and diagnosis. Factor analysis revealed a single dominant component, making it reasonable to combine all questions into a single score. Internal consistency and test-retest reliability were 0.92 and 0.95, respectively. Based on test-retest reliability, the value for a true change in the score was 9.0 points. The International Knee Documentation Committee Subjective Knee Form score was related to concurrent measures of physical function (r = 0.47 to 0.66) but not to emotional function (r = 0.16 to 0.26). Analysis of differential item function indicated that the questions functioned similarly for men versus women, young versus old, and for those with different diagnoses. In conclusion, the International Knee Documentation Committee Subjective Knee Form is a reliable and valid knee-specific measure of symptoms, function, and sports activity that is appropriate for patients with a wide variety of knee problems. Use of this instrument will permit comparisons of outcome across groups with different knee problems.

Factor Analysis, Statistical↗

PubMedDate not supplied

Nurses' documentation of infection control precautions: 2.

A small action research study was undertaken, using a quasi-experimental approach, to establish to what extent infection control advice was documented and to assess the effectiveness of the provision of an example care plan for control of infection. The study population comprised two groups of patients colonized or infected with ALERT organisms and involved 28 wards in six hospitals. Baseline data confirmed that infection control precautions were documented for less than 25% of patients overall. Provision of an 'example' care plan, together with guidance in its use, was followed by an increase in documentation for all items audited, while identification of the infection in the care plan showed a statistically significant increase (P < 0.05). However, in spite of this apparent improvement the documentation of appropriate care for control of infection remained inadequate. It is concluded that, while various strategies to effect change are at the infection control nurse's disposal, the need to integrate infection control with practice must be addressed at every level to include managers, educators and practitioners.

Education, Nursing, Continuing↗

PubMed1979

The collection and analysis of documents for the Civil Liberties and Sexual Orientation Project.

This article shows how documents are collected and analyzed as part of a complex methodology to supplement and verify data gathered for the Civil Liberties and Sexual Orientation Project. During interviews, respondents are shown a checklist and asked if they have documents that may support their belief that they have experienced discrimination. Interviews are considered fully documented if materials are obtained which demonstrate that action was taken against a respondent and that the action was based on sexual orientation or on departures from social sex-role stereotypes. Documents are also collected to see if other attributes of a respondent were involved in the action. In addition, supplemental information is obtained that augments interview data.

Civil Rights↗

PubMed2005

Analysis of factors contributing to 674 agricultural driveline-related injuries and fatalities documented between 1970 to 2003.

Unguarded agricultural power take-off (PTO) drivelines and related components, including secondary drivelines powered by the PTO, have been historically recognized as serious farm-related hazards that can cause severe, permanently disabling injuries and death when entanglement occurs. The lack of longitudinal and causative data on these incidents has been a barrier for developing relevant and effective intervention strategies. A study was conducted at Purdue University to design, develop, and test a system to document, code, store, and analyze a large amount of agriculture driveline-related injury and fatality data to allow for identification of causative factors and trends that could be used in developing engineering, educational, and regulatory solutions. This was accomplished by first developing a standardized injury reporting form and coding system and then developing an electronic database, using Microsoft(R) Access 2002,(R) which could be used to document, store, query, and analyze agricultural driveline-related incident data. Incidents resulting in injury or fatality identified between 1970 and 2003 were documented and the available data coded and entered into the database using a systematic approach. A pilot-test of the usability of the database was conducted on data collected from 92 incidents involving children and adolescents. Using the validated data management system, an analysis was conducted on data collected from 674 cases entered into the database. Findings from the analysis of the data included the following: the frequency of documented agricultural driveline-related incidents increased from the 1970s to the 1980s, but then decreased through the 1990s and into the 2000s; the 11 to 15-year-old age group had the highest frequency of cases; incidents occurred more often in the fall season; and augers, elevators, or conveyors were the type of implements most frequently involved. Recommendations were made to reduce the risk of agriculture driveline injuries and for future research.

Accidents, Occupational↗

PubMed2004

Relative chronology of violent and nonviolent themes in early Christian and Islamic historical documents.

Early Islamic and Christian documents were divided into early and late periods chronologically and then compared to Morgan-Miller's 2002 themes of violence and nonviolence. No significant relationship between chronology and violence themes was found for the Christian documents but for the Islamic documents a significant relationship was detected, with later documents (those revealed at Madinah) reporting a higher percentage of violent and a lower percentage of nonviolent themes than those revealed earlier (at Mecca).

Christianity↗

PubMedDate not supplied

Evaluation of nursing documentation of patient teaching.

The preprinted interdisciplinary care plan is an effective tool in increasing the documentation of patient teaching onto the patient education record; however, when combined with praise and chart audits, the preprinted document becomes even more effective. This study indicates that reinforcement in the form of a preprinted care plan combined with inservice education and audit increases documentation of patient education more than the use of the preprinted document alone.

California↗

PubMed1999

Extended field-of-view two-dimensional ultrasonography of the breast: improvement in lesion documentation.

The purpose of this study was to evaluate the use of extended field-of-view two-dimensional ultrasonographic imaging for improvement in overall breast lesion documentation. Sonographic images of 59 patients with breast lesions or silicone implants were evaluated by three radiologists retrospectively to compare traditional static linear array images alone with images obtained with the addition of an extended field of view to determine if documentation of lesions was improved. The addition of extended field-of-view imaging improved lesion conspicuity by 21% over traditional images. It provided overall improvement in lesion documentation by including a reference point (nipple) or by more completely imaging large masses in 79% and implants in 69%. The larger field of view of this technique is promising as an adjunct to traditional sonography for breast lesion documentation.

Aged↗

PubMed1995

Document imaging: long-term solution or stop-gap measure?

Just what exactly does a "paperless office" mean? To some healthcare professionals, it means just that-no use of paper documents whatsoever. But to others, "paperless" more or less means using paper documents to reach a higher level of electronic recording, in other words-document imaging. We asked four industry insiders to discuss their views and opinions on the use of document imaging in healthcare. Their comments follow.

Forms and Records Control↗

PubMed1997

Education of clinical nurses in nursing documentation in accordance with the VIPS-model.

The purpose of this study is to describe some effects on the clinical nursing documentation after registered nurses (RN) had participated in a three-day course in nursing documentation in accordance with the VIPS-model. Between November 1993 and December 1996, 4594 registered nurses participated in the course. In order to evaluate the effects of the course two questionnaires were sent out to 900 participants, one concerning the degree of development in their nursing documentation and another concerning what they perceived as inhibitors and facilitators to the development of nursing documentation. The result will be presented at the conference.

Computer User Training↗

PubMed1999

WWW search engine for Slovenian and English medical documents.

The information tool for the organization and searching of Slovenian and English medical documents is presented. The tool, partly still in development phases, performs automatic subject description of documents, searching with natural language queries and rankig of search hits according to their relevance. The search engine allows the searcher to use relevance feedback in order to perform incremental improvement of search results. The machine learning system TILDE for learning user profiles was also applied. Documents marked by the user as relevant or non-relevant are used to find characteristics that distinguish relevant documents from non-relevant ones.

Abstracting and Indexing↗