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[Standardized documentation system for the complementary sector of psychiatric care. Development and trial in Saxony].

The necessity for a standardized documentation system for the complementary sector of psychiatric care is pointed out, and the goals and requirements to be met are debated. The test-version of such a documentation system (abbrev. BADO-K) is shown. It consists of modules for the assessment of client-centered data, and for the documentation of the treatment process in various facilities. Furthermore, a module of questionnaires and instruments for assessing outcome variables (e.g. quality of life) is integrated. The principles for using the paper-pencil-version and the EDP-version are outlined and discussed with regard to the legal regulations concerning the protection of personal data. Finally, possibilities and limitations of the presented documentation system are discussed. It is argued that the BADO-K is an useful instrument for evaluating the process and outcome of community psychiatric care.

Community Mental Health Services↗

Prevalence and documentation of impaired mental status in elderly emergency department patients

OBJECTIVE: To determine the prevalence and assess documentation by emergency department (ED) physicians (EPs) of impaired mental status in elderly ED patients. METHODS: Cross-sectional, observational study. Subjects: convenience sampling of ED patients greater than or equal to 70 years of age. Patients were screened for cognitive impairment with the Orientation Memory Concentration exam (OMC), and for delirium with the Confusion. Assessment Method screening tool (CAM). A positive OMC or CAM was considered indicative of impaired mental status. Patients with delirium were excluded from the cognitive impairment screen. EPs were blinded to screening results. Physician documentation, dispositions, and referrals were abstracted from chart review. Proportions and 95% confidence intervals (CIs) are reported. RESULTS: 180 patients were screened. 46 patients (26%; 95% CI = 19% to 32%) had impaired mental status. 22 of these (12%; 95% CI = 7% to 17%) had delirium, and 24 (13%; 95% CI = 8% to 18%) had moderate to severe cognitive impairment. Of all patients with impaired mental status, only 14 (30%; 95% CI = 18% to 46%) had documentation of any impairment by the EP (10 with delirium (46%; 95% CI = 24% to 68%), and 5 with cognitive impairment (21%; 95% CI = 7% to 42%). 7 of 22 (32%; 95% CI = 14% to 55%) patients with delirium were discharged home. Only 2 of 16 patients with impaired mental status (12.5%) were discharged home with plans noted to address the impairment. CONCLUSIONS: Impairment in mental status is highly prevalent among older ED patients. Lack of documentation and referrals by EPs suggests lack of recognition of these problems. Further education of physicians is needed to improve care in these areas.

Journal Article↗

Cryptographic framework for document-objects resulting from multiparty collaborative transactions.

Multiparty transactional frameworks--i.e. Electronic Data Interchange (EDI) or Health Level (HL) 7--often result in composite documents which can be accurately modelled using hyperlinked document-objects. The structural complexity arising from multiauthor involvement and transaction-specific sequencing would be poorly handled by conventional digital signature schemes based on a single evaluation of a one-way hash function and asymmetric cryptography. In this paper we outline the generation of structure-specific authentication hash-trees for the the authentication of transactional document-objects, followed by asymmetric signature generation on the hash-tree value. Server-side multi-client signature verification would probably constitute the single most compute-intensive task, hence the motivation for our usage of the Rabin signature protocol which results in significantly reduced verification workloads compared to the more commonly applied Rivest-Shamir-Adleman (RSA) protocol. Data privacy is handled via symmetric encryption of message traffic using session-specific keys obtained through key-negotiation mechanisms based on discrete-logarithm cryptography. Individual client-to-server channels can be secured using a double key-pair variation of Diffie-Hellman (DH) key negotiation, usage of which also enables bidirectional node authentication. The reciprocal server-to-client multicast channel is secured through Burmester-Desmedt (BD) key-negotiation which enjoys significant advantages over the usual multiparty extensions to the DH protocol. The implementation of hash-tree signatures and bi/multidirectional key negotiation results in a comprehensive cryptographic framework for multiparty document-objects satisfying both authentication and data privacy requirements.

Computer Communication Networks↗

Impact of on-site social work services on the documentation of client and family-centered information: the experience of Ryan White CARE Act (Title IV) pediatric program sites in Maryland.

BACKGROUND: The purpose of this study is to (1) describe client and maternal demographic, social, and medical characteristics of pediatric clients receiving medical and social services at Ryan White (Title IV) program sites, and (2) determine the impact of on-site social work services in documenting client and family-related information used to assess the psychosocial needs of the families affected by human immunodeficiency syndrome and acquired immunodeficiency syndrome (HIV/AIDS). METHODS: We studied infants born to known HIV-infected women who received HIV-related medical services at a federally funded Title IV Ryan White CARE Act provider site in Maryland. Eligibility criteria included < 24 months of age at time of initial clinic visit, a history of birth to a known HIV-infected woman, and a minimum of one comprehensive clinical visit for medical evaluation at a selected Title IV provider site. Study populations were categorized into three independent clinic cohorts. A pre- and postintervention study design was used to assess the impact of the intervention (i.e., on-site social work activities) on variables of interest. Clinic cohorts were (a) preintervention group (N = 181), from January 1, 1986 to December 31, 1989; (b) initial postintervention group (N = 216), from January 1, 1991 to December 31, 1992; and, (c) long-term postintervention group (N = 197), from January 1, 1993 to March 1, 1994. Client and maternal demographic, social, and medical information were recorded and statistical comparisons between pre- and postintervention clinic cohorts were completed with the use of standard statistical methods. RESULTS: Pediatric clients were predominantly African American (94%), lived in low-income family units reflected by the prevalence of public assistance programs (i.e., Medicaid), had a high likelihood of Medicaid enrollment (> 80%), and reported a high frequency of social disruption (e.g., protective services interventions and housing difficulties). Greater than half of all medical records documented the "mother" as the client's primary caregiver in the three cohorts (a,b,c, above) pre- and postintervention cohorts, 51%, 65%, and 66.5%, respectively. Over two-thirds of the mothers among all cohorts were reported to have a current or past history of illicit drug use or alcohol abuse, 69%, 62%, and 67.5%, respectively. Postintervention groups, both initial and long term, were significantly more likely than the preintervention group to have documented medical record information relevant to a history of protective services, housing problems, and maternal demographic, social, and clinical information. Maternal HIV-related clinical status and select social factors (e.g., drug use, housing) remained underreported in both postintervention groups. CONCLUSIONS: Title IV pediatric clinical sites deliver services to a predominantly urban, poor, minority community-the population at greatest risk for pediatric HIV-infection in Maryland. Alternative family members as the primary caregiver for infants and children was common and increased over time. These findings demonstrate that Title IV funded programs have been successful in the documentation of valuable client and maternal information necessary for the development of family-centered clinical and support services to a highly vulnerable population of HIV at-risk or infected infants and children in Maryland.

Adult↗

Use of a template to improve documentation and coding.

BACKGROUND AND OBJECTIVES: Accurate assignment of evaluation and management (E&M) codes is a challenge for physicians. Having guidelines close at hand during patient visits might improve appropriateness and accuracy of E&M coding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentation and coding decisions. METHODS: Fifty office visits for sore throat were documented using templates and were compared with 50 sore throat visits that were documented using progress notes. We counted history and physical examination items and compared the level of service charged to the level of service supported by the note. RESULTS: Significantly more history of present illness and physical examination items were recorded on templates. Decisions related to treatment for patients with a low probability of GABHS were also improved by the templates. Templates had no effect on billing and coding errors. CONCLUSIONS: The template resulted in more-thorough documentation but had no effect on coding and billing errors relative to progress notes.

Adult↗

Exposure assessment of upper limb repetitive movements: a consensus document developed by the Technical Committee on Musculoskeletal Disorders of International Ergonomics Association (IEA) endorsed by International Commission on Occupational Health (ICOH).

This consensus document intends to supply a set of definitions, criteria and procedures useful to describe and, wherever possible, to assess the work conditions that can represent a physical overload for the upper limbs. The document is aimed at all the operators, i.e. occupational doctors but mainly technicians, who are, involved in risk exposure assessment and management. The document intends to provide methods and procedures easily applicable in the field, possibly not requiring sophisticated instrumentation and when possible based on observation procedures. The proposed methods shall be based as far as possible on knowledge and data from scientific literature: should they be contradictory or deficient, reference will be made to standards or pre-standards issued by national and international agencies and bodies, with the experience of researchers involved and common sense. In this regard, it is to be emphasized that the potential users increasingly demand an easily applicable method for description and assessment of work with repetitive movements. The group intends to give a response even if there are still uncertainties from a strictly scientific standpoint: however the group commits itself to perform subsequent validations especially of as yet unconsolidated issues. This document focuses specifically on identification of risk factors and describes some of the methods that have been developed for evaluating them. There is a rapidly developing body of literature on job analysis and not yet agreement on a single best way to analyze jobs. Professional judgement is required to select the appropriate methods. Analysis and design of jobs should to be integrated into an ongoing ergonomics program that includes management commitment, training, health surveillance, and medical case management. In summing up this report, space must be given to the check lists that are so often seen in the medical press, although this is not the occasion to propose a detailed analytical review.

Arm↗

Documentation of smoking: role of age, gender, and ethnicity.

This study assessed the role of age, gender, and ethnicity in chart documentation of smoking by primary care providers. Clinic patients (n = 304) were asked their smoking status and medical records were reviewed. Twenty-nine percent of reviewed patients were smokers, 27.6% former smokers, and 43.1% nonsmokers. Providers were more likely to document smoking among males (OR = 4.6; 95% CI = 2.2-9.5), middle-aged patients (OR = 4.0; 95% CI = 1.4-11.0), and smokers (OR = 8.1; 95% CI = 4.1-16.0). Data revealed selective documentation of smoking in males and middle-aged patients by providers, suggesting gender and age bias in the recognition and documentation of this risky behavior. We conclude that providers should screen for smoking in all patients regardless of age or gender.

Adult↗

Comparison of the elemental composition of office document paper: evidence in a homicide case.

Fraudulent substitution of a page within a multiple page document such as a will or business contract, the counterfeit manufacture of paper banknotes, and linking ransom or extortion notes have all been the focus of criminal investigations at one time or another. In a recent homicide investigation, document examiners were requested to compare a threatening letter received by a business partner of the deceased with paper samples seized under warrant from a suspect's house. Through a quantitative elemental analysis of the concentrations of nine elements (Na, Mg, Al, Mn, Sr, Y, Ba, La, and Ce) within the questioned and specimen documents, determined by inductively coupled plasma-mass spectrometry (ICP-MS), it was concluded that (i) the paper of the threatening letter originated from a different source to that of the paper seized from the suspect's house and (ii) all six pages of paper seized from the suspect's house originated from the same source. This discrimination of paper is presented as both a statistical t-test analysis (99.9% confidence limit) as well as construction of an elemental fingerprint for individual replicates within the questioned and specimen sample populations. This is the first reported use of the comparison of the elemental composition of document paper, determined by ICP-MS, to assist in a criminal investigation.

Journal Article↗

Some aspects of normal behavior: their use in understanding problems encountered by document examiners.

The premise that progress in document examination will depend on employing techniques useful in the more formal branches of science is not exactly logical. The correlation between the work of the document examiner and the behavioral sciences has been discussed by presenting some random thoughts which have occurred to the author over a period of years. The suggestion is made, by illustration and implication, that the unfortunate connotation of the word "behavior" with the word "graphology" has tended to direct the attention of document examiners away from a study of the behavioral sciences, a branch of science from which much can be learned. The fact that the subjective concepts of probability formed by the mature document examiner will approach mathematical expectation has been noted.

Behavior↗

Improving prescription documentation in the ambulatory setting.

Use of a standard prescription pad, although it adequately meets the needs of drug delivery, requires the physician to document prescribed medications separately in the medical record. Failure to do so may lead to under-recognition of problems of potential drug interactions and adverse drug reactions, delays in prescription refills, and other areas of quality of care, especially in a setting where multiple physicians may be involved in the care of a patient. Of 83 prescriptions written in a primary care clinic, only 11 (13%) were noted on the chart medication form when physicians used prescription pads. Implementation of a "one-write" noncarbon prescription form that generated an instant copy increased prescription documentation to 83% (49 of 59 prescriptions) (x2 = 68.86; p < 0.005) over a one-week period. In a follow-up study conducted approximately 3.5 years after the initial intervention, use of the "one-write" form had maintained at 82% prescription documentation (32 of 39) prescriptions) (x2 = 52.05; p < 0.005). A "one-write" copy system could improve clinical care by improving medication documentation in the medical record.

Ambulatory Care↗

[Pictures and documents from the journey of the count palatine Ottheinrich to Cracow and Berlin in 1536/37].

Just in time for teh 500th anniversary of the count palatine and later elector Ottheinrich (1502-1558) in April 2002, it became known that to this Renaissance rule we owe the earliest pictures of towns and residences from Upper Bavaria, Franconia and the Upper Palatine, from Bohemia, Silesia, Poland, Brandenburg and Saxonia. These pictures are the first series of town views after the wood engravings of the Schedel World Chronicle of 1493. Fifty plates in the size of about 30 x 40-86 cm show seventy town views, of which before only the cities of Breslau, Neisse, Prag and Eichstätt were reproduced in the work of 1493. For centuries the genesis of these pen-and-ink-drawings, coloured with watercolour and opaque water colour and ornamented with heightened gold, lay in obscurity. We only knew that they came from the monastery of Ebrach to the university library of Wurzburg in the course of teh secularisation in the year 1803. Lately these pictures, that show no signatures, but only the names of towns in the banderoles, could be identified as picture documents of a rather unknown journey of the Count Palatine Ottheinrich to Cracow and Berlin. The reason for Ottheinrich's journey was to discharge the unpaid promissory note of the marriage portion of his grandmother, the Polish Princess Hedwig who had married George the Rich of Bavaria-Landshut in 1475. The examination of hte pictures and their genesis, made by Angelika Marsch together with ten German, Polish and Czech scientists, also led to the finding of hitherto unknown documents proving that Ottheinrich's ride to his great-uncle King Sigismund the Elder had been successful. These documents also show by whom Ottheinrich was accompanied and why he didn't choose the direct way back from Cracow to Neuburg, but via Berlin. These journey pictures of Ottheinrich date fom the early times of the depiction of real towns. At the same time the first handed down picture documentation of a principal journey is of great interest for different fields of cultural history. The pictures are of special interest for the depicted towns, since they show views of buildings elsewhere not handed down, e.g. the living tower of the "Piasten" in Oberglogau or the cathedral of suburbia of Liegnitz which was laid down four later because of the refortification of the town. The artist of the pictures could not be clearly traced down, but probably belonged to the circle around Albrecht Dürer. It is assumed that it was Mathias Gerung, who also illustrated the Bible for Ottheinrich and made sketches for tapestry carpets. The artist accompanying Ottheinrich can only have made sketches during the journey, which he converted later to our plates in the size of up to 76 cm in width.

Books, Illustrated↗

On the non-equivalence of documented cadaver lengths to living stature estimates based on Fully's method on bones in the Raymond A. Dart Collection.

Regression equations for stature estimation have been derived from documented cadaver lengths available as part of the demographic information in the catalogue of skeletonised remains in different collections around the world. The Raymond A. Dart Collection is one such collection, but the reliability of documented cadaver lengths in it has been previously questioned. The aim of this study was to compare these lengths with estimated living stature using Fully's anatomical method. Living stature was estimated with this method from a total of 156 complete skeletons obtained from the Collection. These heights were then compared with the documented cadaver lengths. It was observed that the documented cadaver lengths were significantly higher than the estimated living stature using Fully's method.

Adult↗

How documentation outcomes guide the way: a patient health education electronic medical record experience in a large health care network.

BACKGROUND: Despite Joint Commission on Accreditation of Healthcare Organizations' standards in patient health education (PHE), the patient education process oftentimes remains underreported in many patients' medical records. The primary focus of this project was to create a usable electronic medical record (EMR)-based method of documentation of PHE within a large Department of Veterans Affairs (VA) health care network using clinical staff involvement, routine monitoring, and consistent feedback. METHODS: A team of clinical staff was formulated to review current literature, seek out best practices, examine existing VA PHE templates, and create and monitor a user-friendly EMR process for documenting the assessment of patient learning needs and the outcomes of teaching and education. Professional team focus groups, pilot testing, usage monitoring, local action planning, and feedback surveys were selected strategies utilized to create and evaluate success and make timely revisions. RESULTS/RESPONSE: Monthly usage reports were provided to the local PHE teams. An EMR monitoring system for clinical reminders provided an appropriate and tested mechanism to collect specific usage data. Since 2003, steady improvement has been reported with use partly due to greater acceptance of the process and growing competition among network sites. The newly created PHE EMR has since been modified to enhance the quality of documentation as staff becomes more adept at using these tools. CONCLUSION: Staff involvement in format design and development combined with consistent feedback and evaluation resulted in improved documentation compliance. Future work is focused on the quality of evaluations of patient learning needs and electronic recording of patient teaching and education.

Hospitals, Veterans↗

Computer-based nursing documentation in nursing homes: A feasibility study.

The burden of paper-based nursing documentation has led to increasing complaints and decreasing job satisfaction amongst aged-care workers in Australian nursing homes. The automation of nursing documentation has been identified as one of the possible strategies to address this issue. A major obstacle to the introduction of IT solutions, however, has been a prevailing doubt concerning the ability and/or the willingness of aged-care workers to accept such innovation. This research investigates the attitudes of aged-care workers towards adopting IT innovation. Questionnaire survey were conducted in 13 nursing homes around the Illawarra and Sydney regions in Australia. The survey found that an unexpected 89.3% of participants supported the strategy of introducing electronic nursing documentation systems into residential aged-care facilities. 94.3% of them would use such a system depending on circumstances. Despite a shortage of computers in the workplace, which is a major barrier, this research provides strong evidence that care workers in residential aged-care facilities are willing to accept electronic nursing documentation practice and the uptake of information technology in residential aged-care is feasible in Australia.

Adult↗

A systematic approach to baseline assessment of nursing documentation and enterprise-wide prioritization for electronic conversion.

An important challenge associated with making the transition from paper to electronic documentation systems is achieving consensus regarding priorities for electronic conversion across diverse groups. In our work we focus on applying a systematic approach to evaluating the baseline state of nursing documentation across a large healthcare system and establishing a unified vision for electronic conversion. A review of the current state of nursing documentation across PHS was conducted using structured tools. Data from this assessment was employed to facilitate an evidence-based approach to decision-making regarding conversion to electronic documentation at local and PHS levels. In this paper we present highlights of the assessment process and the outcomes of this multi-site collaboration.

Delivery of Health Care↗

Documentation: short, simple, and meaningful.

Nursing diagnosis has been incorporated into the documentation in our neonatal units because it gives nurses credit for their unique functioning, provides for consistency in communication, facilitates continuity of care, and is therefore likely to improve the quality of nursing care. The documentation system utilizes flow sheets to document physiological functioning. The nursing progress note/individualized patient care plan provides for a narrative note and continuous update of the patient care plan, keeping it current and meaningful. Previous care plans have involved massive writing about nursing actions. By providing reference tools that list the actual nursing actions, this system allows the nurse's written documentation to describe what the focus of the nurse's work has always been: the patient and the patient's responses to nursing care.

Forms and Records Control↗

Health professionals' use of documents obtained through the Regional Medical Library Network.

The Pacific Southwest Regional Medical Library Service (PSRMLS) studied how health professionals use documents obtained through the regional medical library (RML) network and how various factors, such as delivery time, affected that use. A random sample of libraries in Region 7 of the RML network was selected to survey health professionals who had received documents through the interlibrary loan (ILL) network. The survey provided data about the purposes for which health professionals requested documents, how the immediacy of need for the items affected their usefulness, what effect the obtained information had on the health professionals' work, and whether the illustrations represented an important part of the information content of the items. Survey results provided a positive assessment of the ILL network. Results also verified the basic value of the materials provided to health professionals through ILL and identified some areas for consideration in future network development. Users of the documents indicated that the network works efficiently and effectively to provide timely and useful information needed by health professionals. Technological developments in electronic information transmission and imaging will further enhance network operation in the future.

Health Occupations↗

Government documents and the online catalog.

Prior to planning for implementing the NOTIS system, the Vanderbilt Medical Center Library had not fully cataloged its government publications, and records for these materials were not in machine-readable format. A decision was made that patrons should need to look in only one place for all library materials, including the Health and Human Services Department publications received each year from the central library's Government Documents Unit. Beginning in 1985, these publications were added to the library's database, and the entire 7,200-piece collection is now in the online catalog. Working with these publications has taught the library much about the advantages and disadvantages of cataloging government documents in an online environment. It was found that OCLC cataloging copy is eventually available for most titles, although only about 10% of the records have MeSH headings. Staff time is the major expenditure; problems are caused by documents' irregular nature, frequent format changes, and difficult authority work. Since their addition to the online catalog, documents are used more and the library has better control.

Cataloging↗