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At least 649 records · Page 36Linked to original sources
PubMed1992

Comparison between tape-recorded and amplitude-integrated EEG monitoring in sick newborn infants.

In 15 ill newborn infants a comparison between long-term multichannel and single-channel recordings of simultaneously tape-recorded (Medilog system) and amplitude-integrated EEG (Cerebral Function Monitor) was made. There was good agreement between the main type of background activity diagnosed with the tape-recorded and the amplitude-integrated EEG for all recordings. Two infants had repetitive subclinical and subtle seizure activity, lasting for several hours, which was detected by both techniques. Short, single seizures were diagnosed in the recordings of nine infants. When a single electrographic seizure appeared in an otherwise stable recording, it was identified by both the tape-recorded and the amplitude-integrated EEG. Very short (5-30 s) seizure patterns, which were diagnosed with the tape-recorded EEG, were not identified in the cerebral function monitor recordings. In the single-channel recordings of both the EEG and the cerebral function monitor there were, on some occasions, difficulties in distinguishing single seizures from interference due to external artefacts. In the multichannel recordings the diagnosis of seizure patterns was facilitated by comparison with the other channels. Both the Medilog EEG and the cerebral function monitor are feasible techniques for following cerebral electrical activity in sick neonates, although neither technique is specifically constructed for this purpose. For clinical use in the neonatal intensive care unit the advantage with the cerebral function monitor is the immediately available recording. The tape-recorded EEG offers possibilities of more channels and a higher reliability when diagnosing short subclinical seizures, however, only after offline analysis.

Electroencephalography↗
PubMed2006

Using video recording to identify management errors in pediatric trauma resuscitation.

OBJECTIVE: To determine the ability of video recording to identify management errors in trauma resuscitation and to compare this method with medical record review. METHOD: The resuscitation of children who presented to the emergency department of the Royal Children's Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. RESULTS: Ninety resuscitations were video recorded and analyzed. An average of 5.9 errors per resuscitation was identified with this method (range: 1-12 errors). Twenty-five children (28%) had an injury severity score of >11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement. CONCLUSIONS: Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

Adolescent↗
PubMed1991

Risk management: role of the medical record department.

Good record-keeping practices contribute to the high quality of the medical record. Is the medical staff actually aware of the multiple uses of the medical record today as opposed to only a few years ago? This is all in keeping with multiple requirements for accreditation, state licensing requirements, hospital medical staff rules and regulations, and a more aggressive consumer. Physicians and attorneys alike depend on the documentation in the medical record to support their case. An independent detailed recollection of the case by caregivers without use of the medical record would be extremely difficult. Nothing can take the place of an accurate account of the patient's care in the medical record. Defense in the absence of supporting documentation would be very weak, if not lost. It is clear that inadequate or incomplete medical records expose the physician and the hospital to risk. Hospital rules and regulations should be strictly enforced to enhance patient care and to avoid potential legal action. If documentation problems are identified, utilize the medical staff committees for recommendations and action. Medical records are an integral part of patient care responsibility and should be treated as such. The medical record is a legal document that is the most reliable record of care rendered to the patient. In legal settings, the record will be scrutinized by expert witnesses for the plaintiff and the defense. What the records do not contain may be as important as what they do contain when there is an allegation that the patient's condition warranted intervention or action that was not taken.

Documentation↗
PubMed2004

A new non-invasive method for recording the electro-olfactogram using external electrodes.

OBJECTIVE: The aim of this investigation was to explore the possibility of recording the electro-olfactogram (EOG) using external electrodes placed on the root of the nose on either side of the bridge and at the medial termination of the eyebrows. The EOG is considered to be the summated generator potential of olfactory receptor cells and therefore represents peripheral olfactory events. Recording of human EOG is technically difficult due to poor access to the olfactory mucosa and the nasal irritation is tolerated by few subjects. METHODS: The evoked potentials at these sites in response to two odourants, n-amyl acetate and benzaldehyde, were recorded simultaneously with the EOG, recorded conventionally with an intranasal electrode, and the olfactory event-related potential (OERP) recorded using scalp electrodes. RESULTS: The extranasal potential recorded at the root of the nose, 0.5-1 cm below the nasion, 1 cm from the ridge and ipsilateral with the stimulus, had the highest degree of correlation with the intranasal EOG. We refer to this site as N1 (left side) and N2 (right side). Further analysis demonstrated that the latency, the time constant of the rising phase and the amplitude of the evoked potential recorded at N1 also had a higher correlation coefficient with the EOG than did those potentials recorded at other sites. Statistical analysis indicated that the latency and time constant of the response recorded externally at N1 were the same as those of the EOG recorded intranasally. CONCLUSIONS: We conclude that an olfactory evoked potential, with many of the characteristics of the EOG recorded from the olfactory mucosa, can be recorded externally at a site close to the bridge of the nose. SIGNIFICANCE: This non-invasive method of recording the EOG will have benefits for the objective assessment of olfactory function.

Adult↗
PubMed2006

Generalized tonic-clonic seizures detected by implantable loop recorder devices: diagnosing more than cardiac arrhythmias.

BACKGROUND: Both syncope and seizures are important causes of recurrent, unexplained episodes of loss of consciousness. Implantable loop recorders have identified serious arrhythmias in patients with repeated syncope; however, implantable loop recorder detection of seizures is less well established. OBJECTIVES: The purpose of this study was to provide in-depth analysis of a characteristic myopotential pattern recorded by implantable loop recorders during generalized tonic-clonic seizures. METHODS: Fourteen patients with refractory, video-EEG-documented epilepsy (complex partial, atonic, tonic, or generalized tonic-clonic seizures) underwent implantable loop recorder placement as part of a study protocol evaluating cardiac rhythm abnormalities in patients at high risk for sudden unexpected death in epilepsy. RESULTS: Twelve generalized tonic-clonic seizure episodes were detected by the implantable loop recorder in six patients. Implantable loop recorder and EEG recordings of generalized tonic-clonic seizures were identical and revealed a tonic phase (sustained, rapid, high-frequency myopotentials) transitioning to a clonic phase (periodic bursts of high-frequency myopotentials with a decelerating burst frequency from 3-6 Hz to 1-2 Hz) prior to seizure termination. With the nonprogrammable bandpass filter of 0.85 to 32 Hz in the implantable loop recorder, all generalized tonic-clonic seizure episodes had escaped automatic detection and required activation by family members. None of the 76 nongeneralized tonic-clonic seizure episodes recorded on the implantable loop recorder in the 14 patients exhibited the stereotypical tonic-clonic pattern that defines generalized seizures. CONCLUSION: Recognizing this specific myopotential pattern on an implantable loop recorder might help diagnose generalized tonic-clonic seizures as a cause of recurrent, unexplained episodes of loss of consciousness. Having a programmable bandpass filter in the implantable loop recorder might increase its diagnostic yield for such patients.

Adult↗
PubMed2005

Are there limits to running world records?

PURPOSE: Previous researchers have adopted linear models to predict athletic running world records, based on records recorded throughout the 20th century. These linear models imply that there is no limit to human performance and that, based on projected estimates, women will eventually run faster than men. The purpose of this article is to assess whether a more biologically sound, flattened "S-shaped" curve could provide a better and more interpretable fit to the data, suggesting that running world records could reach their asymptotic limits some time in the future. METHODS: Middle- and long-distance running world record speeds recorded during the 20th century were modeled using a flattened S-shaped logistic curve. RESULTS: The logistic curves produce significantly better fits to these world records than linear models (assessed by separating/partitioning the explained variance from the logistic and linear models using ANOVA). The models identify a slow rise in world-record speeds during the early year of the century, followed by a period of "acceleration" in the middle of the century (due to the professionalization of sport and advances in technology and science), and a subsequent reduction in the prevalence of record-breaking performances towards the end of the century. The model predicts that men's world records are nearing their asymptotic limits (within 1-3%). Indeed, the current women's 1500-m world record speed of 6.51 m x s(-1) may well have reached its limit (time 3:50.46). CONCLUSIONS: Many of the established men's and women's endurance running world records are nearing their limits and, consequently, women's world records are unlikely to ever reach those achieved by men.

Competitive Behavior↗
PubMed2000

[An automated electronic anesthesia record using a hospital LAN (local area network)].

We have developed an automated electronic anesthesia record system using a hospital LAN. As the number of monitors we can use in the operating room is increasing, it is impossible to record all physiologic parameters in a handwritten anesthesia record. Physiologic parameters are recorded every 10 seconds from the anesthesia monitor. An operation ordering system by a hospital LAN has been completed and the patient's data are stored in a host computer, and we can use its data for the automated electronic anesthesia record preoperatively. The advantages of the automated electronic anesthesia record are continuous high quality, more data collection than the handwritten anesthesia record, and the electronic database. During a critical period, the anesthesiologist is too busy to plot physiologic parameters but the automated electronic anesthesia record is reliable and accurate. Disadvantage of the automated electronic anesthesia record is some practice required to input clinical events such as drug administration. The handwritten anesthesia record is easy to use and economical. Ergonomic problems still remain to be solved for wider acceptance of the automated electronic anesthesia record in clinical practice. At the end of the operation, intraoperative data are sent to a host computer and the anesthesia record is printed. We can use this database for clinical research and retrospective case reviews. The implementation of the automated electronic anesthesia record in anesthesia practice will improve quality of patient care.

Anesthesia↗
PubMed1996

[Value of unipolar and bipolar recordings in radiofrequency ablation of accessory atrioventricular pathways].

The aim of the study was to compare the value of different modes of endocavitary recordings: unipolar alone, bipolar alone and the association of unipolar and bipolar recordings in radiofrequency ablation of accessory atrioventricular pathways. A retrospective analysis by three independent observers of 135 endocavitary recordings obtained immediately before radiofrequency application in 82 subjects who underwent radiofrequency ablation for symptomatic accessory atrioventricular pathways. In each case, the authors selected the "successful" record which corresponded to the final radiofrequency application and 0.1 or 2 records of "failures". Each initial recording being of 3 types (unipolar, bipolar and association of uni- and bipolar), a total of 390 anonymous and randomised recordings were analysed by the observers who determined whether the appearances indicated successful ablation. Univariate analysis of variants showed a correlation between success with the mode of recording (p = 0.03) and a left lateral position of the accessory pathways. In multivariate analysis, three variables remained correlated with successful ablation: the observer variable (p = 0.001), and two interactions observer - mode (p = 0.005) and observer-stability (p = 0.02). The benefits of the association of unipolar and bipolar recordings with respect to bipolar recording alone, seemed to be important in predicting failure. The results of tests of concordance in the group of failures were confirmatory: concordance between observers was only found between the unipolar mode alone and the association of unipolar and bipolar recordings. The results of this study suggest that the association of unipolar and bipolar endocavitary recordings may reduce the number of unnecessary application of radiofrequency energy by improved identification of recording showing failure.

Adult↗
PubMed2002

Voluntary health workers' knowledge, attitude and practices regarding record keeping in Akinyele LGA of Oyo State, Nigeria.

Lack of basic health data for monitoring and evaluation of health services continue to affect the planning, implementation and evaluation of health services in Nigeria. This has contributed to the poor health status and inefficient health services in the country. In the primary health care management information system (PHCMIS), Voluntary Village Health Workers (VHWs) and Traditional Birth Attendants (TBAs) are responsible for collecting information at the community/village level. Trained research assistants administered a pretested semi structured questionnaire and filled an observation checklist to all the voluntary health workers in Akinyele LGA of Oyo State in a cross-sectional survey conducted to assess their record keeping practices as well as their knowledge of and attitude towards it. Results showed that almost half of the respondents had no formal education and a similar proportion had been VHWs for between over 10 years. Over eighty per cent knew the uses of record keeping for monitoring and evaluation purposes. Their attitude towards it was positive and almost all felt it was easy to keep records. Ninety six percent keep records of their health activities and most forward them. It was observed that only 11 (10.8%) respondents had the VHW/TBA record of work produced and recommended by the Federal Ministry of Health because they were reportedly not supplied to them. The factors that were associated with record keeping practices were positive attitude towards record keeping, duration of work as a VHW/TBA, prior training on record keeping and receiving feedback on records kept. Recommendations made included periodic training and retraining of the VHWs on record keeping, ensuring consistent supply of record forms and providing regular feedback on records kept to the VHWs.

Adult↗
PubMed2002

The electronic oral health record.

This paper presents the history of the use of the computer for maintaining patient medical care information. An electronic record generated with a computer, which is non-specific for any healthcare specialty, is referred to as the electronic health record. The electronic health record was previously called the computer-based patient record. "Electronic" replaced the earlier term "computer-based" because "electronic" better describes the medium in which the patient record is managed. The electronic health record and its application to dentistry are discussed. The electronic health record is a "database" of patient information that has been entered by any healthcare provider; the electronic oral health record is an "electronic record" of oral health information that has been entered by an oral healthcare provider. The significant differences between the electronic health record and the electronic oral health record are outlined and highlighted. Included is a template describing a procedure to be used by dental personnel during the decision making process of purchasing an electronic oral health record. A brief description of a practice template is also provided. These completed templates can be shared with dental software vendors to clarify their understanding of and to clearly describe the needs of today's dental practice. The challenge of introducing information technology into educational institutions' curricula is identified. Finally, the potential benefit of using electronic technology for managing oral healthcare information is outlined.

American Dental Association↗
PubMed2004

Patients' experiences when accessing their on-line electronic patient records in primary care.

BACKGROUND: Patient access to on-line primary care electronic patient records is being developed nationally. Knowledge of what happens when patients access their electronic records is poor. AIM: To enable 100 patients to access their electronic records for the first time to elicit patients' views and to understand their requirements. DESIGN OF STUDY: In-depth interviews using semi-structured questionnaires as patients accessed their electronic records, plus a series of focus groups. SETTING: Secure facilities for patients to view their primary care records privately. METHOD: One hundred patients from a randomised group viewed their on-line electronic records for the first time. The questionnaire and focus groups addressed patients' views on the following topics: ease of use; confidentiality and security; consent to access; accuracy; printing records; expectations regarding content; exploitation of electronic records; receiving new information and bad news. RESULTS: Most patients found the computer technology used acceptable. The majority found viewing their record useful and understood most of the content, although medical terms and abbreviations required explanation. Patients were concerned about security and confidentiality, including potential exploitation of records. They wanted the facility to give informed consent regarding access and use of data. Many found errors, although most were not medically significant. Many expected more detail and more information. Patients wanted to add personal information. CONCLUSION: Patients have strong views on what they find acceptable regarding access to electronic records. Working in partnership with patients to develop systems is essential to their success. Further work is required to address legal and ethical issues of electronic records and to evaluate their impact on patients, health professionals and service provision.

Adult↗
PubMed1995

Evaluating a new algorithm for linking maternal and newborn medical records.

Linking material and newborn medical records is a valuable tool for assessing the relationship between maternal variables and fetal outcome. This study evaluated the Center for Disease Control's newly developed maternal and newborn medical record linkage system, a computer program that uses weighted variables to determine the most likely maternal and newborn pairs. Any newborn record not achieving a set minimum score with a maternal record remains nonmatched. The objectives of the study were to estimate the program's matching accuracy, determine causes of incorrect matches and nonmatches, develop suggestions for program revisions, and evaluate the effects of the revisions. The study sample included 521 matched and 247 nonmatched maternal and newborn medical records from seven Ohio hospitals. Of all available newborn records (10,068), 574 (5.7%) did not match with maternal records; for those in which a match occurred, the authors ascertained a 98% matching accuracy and determined explanations for nonmatched and incorrectly matched records. The authors noted a greater prevalence of birth defects and prematurity among newborns with nonmatched records than among those with matched records. Program revisions, therefore, focused on reducing the prevalence of nonmatched records. The revised program reduced the prevalence of nonmatched records from 5.7% to 3% but reduced matching accuracy.

Algorithms↗
PubMed2006

Documentation on the anesthetic record: Correlation with clinically important variables.

PURPOSE: A survey was undertaken at a single Academic Health Sciences Centre to document the opinions of anesthesiologists regarding what variables are important to document on the anesthetic record. A subsequent chart review of anesthetic records was undertaken to determine the extent to which these anesthesiologists record the variables they consider important. METHODS: A survey form was mailed to all practicing staff anesthesiologists at the four adult McGill University affiliated hospitals. Anesthesiologists were asked to rank 23 preoperative and 33 intraoperative variables on a scale from 1-5: (1 = essential; 2 = important; 3 = useful; 4 = not important; 5 = excessive information). All variables considered by consensus < or = 2 (important to essential) were then assessed as to whether they were recorded on 60 charts randomly selected from each of the four teaching hospitals. Only anesthetic records completed by staff anesthesiologists were evaluated. RESULTS: Ninety percent (47/52) of survey forms were completed and returned. Preoperative variables considered most important to document included examination of the patient's airway and allergy status. Intraoperative variables considered most important for documentation were the patient's vital signs. The only variable to have been recorded on all the anesthetic records was the anesthesiologist's name. The allergy status was the most recorded preoperative variable (84% of charts). The recording rates of intraoperative variables ranged from 100% (anesthesiologist's name, start time of anesthesia) to 24% (estimated blood loss). CONCLUSION: McGill anesthesiologists consider many preoperative and intraoperative variables to be important to document on the anesthetic record. However, subsequent chart review indicated that many of these variables are recorded inconsistently. The transmission of anesthesia-related medical information might be improved if anesthesiologists recorded more consistently information they consider to be important.

Adult↗
PubMed2003

Quality of recording of data from patients with type 2 diabetes is not a valid indicator of quality of care. A cross-sectional study.

BACKGROUND: The quality of recording of clinical data in diabetes care in general practices is very variable. It has been suggested that better recording leads to improved glycaemic control. OBJECTIVES: The purpose of this study was to assess the completeness of recording by GPs of data from type 2 diabetes patients; to compare recorded and missing data; and to investigate the association between completeness and glycaemic control. METHODS: A cross-sectional survey was carried out in 52 general practices. Medical records were scrutinized for the presence of 11 variables. Examining patients through an active approach completed incomplete records. We compared recorded and unrecorded items. Completeness of recording was determined at both patient and practice levels. RESULTS: Fifty-two general practices with 1641 type 2 diabetes patients cared for by the GP participated. The frequency of absence of any particular item ranged from 20 to 70%. Weight, systolic blood pressure and HbA(1c) were slightly lower in patients with those items missing on their files, and more such patients were non-smokers (P < 0.05). The percentage of patients with unrecorded variables that exceeded target values ranged from 39 to 75. Neither at practice level nor at patient level was any association between the completeness of the data recording and HbA(1c) found. CONCLUSION: Records often were incomplete, which hampers a systematic approach to care of diabetic patients. However, the lack of association between completeness of data recording and control of glycaemia indicates that improved recording is not a valid indicator of good quality of care.

Adult↗
PubMed2007

Medical records for animals used in research, teaching, and testing: public statement from the American College of Laboratory Animal Medicine.

Medical records are considered to be a key element of a program of adequate veterinary care for animals used in research, teaching, and testing. However, prior to the release of the public statement on medical records by the American College of Laboratory Animal Medicine (ACLAM), the guidance that was available on the form and content of medical records used for the research setting was not consistent and, in some cases, was considered to be too rigid. To address this concern, ACLAM convened an ad hoc Medical Records Committee and charged the Committee with the task of developing a medical record guideline that was based on both professional judgment and performance standards. The Committee provided ACLAM with a guidance document titled Public Statements: Medical Records for Animals Used in Research, Teaching, and Testing, which was approved by ACLAM in late 2004. The ACLAM public statement on medical records provides guidance on the definition and content of medical records, and clearly identifies the Attending Veterinarian as the individual who is charged with authority and responsibility for oversight of the institution's medical records program. The document offers latitude to institutions in the precise form and process used for medical records but identifies typical information to be included in such records. As a result, the ACLAM public statement on medical records provides practical yet flexible guidelines to assure that documentation of animal health is performed in research, teaching, and testing situations.

Animal Experimentation↗
PubMed2006

Comparison of administrative data and medical records to measure the quality of medical care provided to vulnerable older patients.

BACKGROUND: Administrative data are used to determine performance for publicly reported in health plan "report cards," accreditation status, and reimbursement. However, it is unclear how performance based on administrative data and medical records compare. METHODS: We compared applicability, eligibility, and performance on 182 measures of health care quality using medical records and administrative data during a 13-month period for a random sample of 399 vulnerable older patients enrolled in managed care. RESULTS: Of 182 quality indicators (QIs) spanning 22 conditions, 145 (80%) were applicable only to medical records and 37 (20%) to either medical records or administrative data. Among 48 QIs specific to geriatric conditions, all were applicable to medical records; 2 of these also were applicable to administrative data. Eligibility for the 37 QIs that were applicable to both medical records and administrative data was similar for both data sources (94% agreement, kappa = 0.74). With the use of medical records, 152 of the 182 the QIs that were applicable to medical records were triggered and yielded an overall performance of 55%. Using administrative data, 30 of the 37 QIs that were applicable to administrative data were triggered and yielded overall performance of 83% (P < 0.05 vs. medical records). Restricting to QIs applicable to both data sources, overall performance was 84% and 83% (P = 0.21) for medical records and administrative data, respectively. CONCLUSIONS: The number and spectrum of QIs that can be measured for vulnerable elderly patients is far greater for medical records than for administrative data. Although summary estimates of health care quality derived from administrative data and medical records do not differ when using identical measures, summary scores from these data sources vary substantially when the totality of care that can be measured by each data source is measured.

Aged↗
PubMed1972

Survey of general practice records.

A study of a sample of records from eight general practices showed that 10% of patients' ages were not recorded, that 99% of males had no indication of their marital state, and 60% did not have an occupation recorded. In recording of disease episodes a diagnosis was recorded in a little over half of the episodes and was the only recorded item in 10% of records. The recording of the therapeutic agent used was the most frequently recorded item, occurring in 70% of episodes, but the amount prescribed was recorded in only one-quarter of the episodes and the dosage in less than one-fifth. Less than half of the episodes had any symptoms recorded and only one-third had a physical sign recorded.

Age Factors↗
PubMed2006

Paper versus computer: feasibility of an electronic medical record in general pediatrics.

BACKGROUND: Implementation of electronic medical record systems promises significant advances in patient care, because such systems enhance readability, availability, and data quality. Structured data entry (SDE) applications can prompt for completeness, provide greater accuracy and better ordering for searching and retrieval, and permit validity checks for data quality monitoring, research, and especially decision support. A generic SDE application (OpenSDE) to support documentation of patient history and physical examination findings was developed and tailored for the domain of general pediatrics. OBJECTIVE: To evaluate OpenSDE for its completeness, uniformity of reporting, and usability in general pediatrics. METHODS: Four (trainee) pediatricians documented data for 8 first-visit patients in the traditional, paper-based, medical record and immediately thereafter in OpenSDE (electronic record). The 32 paper records obtained served as the common data source for data entry in OpenSDE by the other 3 physicians (transcribed record). Data entered by 2 experienced users, with all patient information present in the paper record, served as the control record. Data entry times were recorded, and a questionnaire was used to assess users' experiences with OpenSDE. RESULTS: Clinicians documented 44% of all available patient information identically in the paper and electronic records. Twenty-five percent of all patient information was documented only in the paper record, and 31% was present only in the electronic record. Differences were found in patient history and physical examination documentation in the electronic record; more information was missing for patient history (38%) than for physical examination (15%). Furthermore, physical examination contained more additional information (39%) than did patient history (21%). The interobserver agreement of documentation of patient information from the same data source was fair to moderate, with kappa values of 0.39 for patient history and 0.40 for physical examination. Data entry times in OpenSDE decreased from 25 minutes to <15 minutes, indicating a learning effect. The questionnaire revealed a positive attitude toward the use of OpenSDE in daily practice. CONCLUSION: OpenSDE seems to be a promising application for the support of physician data entry in general pediatrics.

Documentation↗