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PubMedDate not supplied

Decreasing documentation time using a patient self-assessment tool.

A 1986 audit of 150 randomly selected radiation therapy patient records revealed 147 records containing completed nursing assessment and weekly progress notes. Documentation of care provided was comprehensive, but concern was expressed over the length of time it required--an average of 40 minutes for the patient interview and an additional 20 minutes for documentation. Two strategies were proposed to reduce the amount of time spent in documentation without jeopardizing the detail of information contained in the initial nursing assessment: to pilot a patient self-assessment tool based on our original functional health pattern nursing assessment and to develop a standard flow sheet that contained both frequently used nursing diagnoses and potential interventions. Selected patients completed self-assessment records and discussed them with their primary nurses on the first day of treatment. Based on the pilot data, the forms were modified and revised. In 1987, 50 revised patient self-assessment records were reviewed revealing that both subjective and objective information had improved. Documentation time was reduced and information was more comprehensive.

Health Status↗
PubMedDate not supplied

[Introduction of diagnostic statistics in accord with section 16 of the Federal Ordinance for Hospitalization Cost Rates (BPflV). Basic documentation for the clinical branch of oral and maxillofacial surgery].

In 1984 a first diagnosis and treatment code was developed for the computer documentation of patient data at the clinical department for oral and maxillofacial surgery of the Münster University Hospital. After a long time of testing and improving in day-by-day practical use, it today includes a total of 126 diagnoses and 169 forms of treatment. When in 1986 the Federal Ordinance for Hospitalization Cost Rates came into power, this documentation system had to be re-coded to comply with ICD 9 and, at the same time, a documentation sheet had to be developed that would meet both the necessary scientific standards and the given administrative criteria. In this paper a documentation sheet is presented that fulfills both requirements and, by virtue of its simplicity, avoids almost any loss of data.

Dental Records↗
PubMedDate not supplied

The impact of a health screening flow sheet on the performance and documentation of health screening procedures.

We monitored physician performance of stool occult blood testing and breast exams during health maintenance visits of patients aged 50 or greater, to assess the impact of a physician education program and the use of a health screening flow sheet on performance of these health screening procedures. During the baseline study period, use of these procedures was documented for only about 40% of patients. A physician education program (conferences reviewing appropriate health maintenance screening procedures, and information on the use of a specific health screening flow sheet) did not significantly change the rate of documented physician performance of these procedures. After a health screening flow sheet was introduced into the medical record, the rate of documented performance of these screening tests increased. However, despite the presence of the screening flow sheet in the patient record, most screening evaluations were documented only in the progress notes. These results suggest that the screening flow sheet serves primarily as a memory prompting device. The usefulness of the flow sheet as a patient data storage device appears questionable.

Breast↗
PubMed1985

The PIE system: complete planning and documentation of nursing care.

To address a number of difficulties with nursing documentation, a process-oriented documentation system called the Problem-Intervention-Evaluation (PIE) system was developed and implemented on a 35-bed medical unit at Craven County Hospital, New Bern, North Carolina. The PIE system simplifies the documentation process and unifies the care plan and progress notes into a complete, concise record of nursing care actually planned and provided. Informal evaluations indicate that the PIE system increases job satisfaction for nursing staff, improves the quality of documentation, and promotes continuity of care from shift to shift and from day to day. The article raises questions for further evaluation.

Humans↗
PubMed1972

Document delivery capabilities of major biomedical libraries in 1968: results of a national survey employing standardized tests.

The standardized Document Delivery Tests (DDT's) developed earlier (Bulletin 56: 241-267, July 1968) were employed to assess the capability of ninety-two medical school libraries for meeting the document needs of biomedical researchers, and the capability of fifteen major resource libraries for filling I-L requests from biomedical libraries. The primary test data are summarized as statistics on the observed availability status of the 300 plus documents in the test samples, and as measures expressing capability as a function of the mean time that would be required for users to obtain test sample documents. A mathematical model is developed in which the virtual capability of a library, as seen by its users, equals the algebraic sum of the basic capability afforded by its holdings; the combined losses attributable to use of its collection, processing, relative inacessibility, and housekeeping problems; and the gain realized by coupling with other resources (I-L borrowing). For a particular library, or group of libraries, empirical values for each of these variables can be calculated easily from the capability measures and the status statistics. Regression equations are derived that provide useful predictions of basic capability from collection size. The most important result of this work is that cost-effectiveness analyses can now be used as practical decision aids in managing a basic library service. A program of periodic surveys and further development of DDT's is recommended as appropriate for the Medical Library Association.

Costs and Cost Analysis↗
PubMed1994

Positive efficiency findings using computer assisted ICD-encoding: 3.5 years of experience with the computerized patient record system PADS (Patient Archiving & Documentation System).

In daily routine there is a major discrepancy between what physicians do and what they document. From a medical information processing point of view amongst the more important functions physicians perform in their daily routine is the encoding of diagnoses using a standard vocabulary such as ICD-9. This paper presents evidence that through the use of the ICD-encoding module of a computerized patient record system (PADS, Patient Archiving and Documentation System) user compliance can be improved. "Bypassing" mechanisms can be partly reversed (up to 43%), more coded diagnoses are documented (by 51%) and those diagnoses documented are more complete (increase by 57%).

Germany↗
PubMedDate not supplied

Bedside terminals and quality of nursing documentation.

In this article, the authors report on part one of a three-part investigation studying the impact of bedside terminals at New York University Medical Center, New York, NY. Using a before-after parallel control-group design, the quality of computerized nursing documentation was studied before and after adding computers to patient rooms. The quality of documentation was defined by timeliness and completeness of data. The study hypothesis, which predicted a positive relationship between the presence of bedside terminals and the quality of nursing documentation, was not supported. Study results showed a minimal use of the computer terminals located in patient rooms. A surprising result was the use of terminals located in rooms other than that of the patient for which documentation was made.

Computer Terminals↗
PubMed1995

'Et in arcadia ego...?' Some notes on methodological issues in the use of psychoanalytic documents and archives.

The author uses archival material, mainly the letters exchanged between Jones and Strachey in the fifties, when Jones was writing his biography of Freud and Strachey was working on the Standard Edition. He shows the complexity of the interaction between these two men; the more or less conscious ambivalences, motivations and resentments against the so-called Freudian establishment of that time. This per se can help us to understand how a 'certain image' of Freud was created in Great Britain during those years and the reasons for its authoritative persistence. Yet the paper touches on more general issues such as those of the fascination with psychoanalytic archives and the more or less accepted and admitted unconscious motivations of the interpreters of these documents too, not excluding myself. The conclusion reached is that even psychoanalytical documents do not rest in a peaceful Arcadia and that archives cannot be considered as the Arcadia of documents--at least not in the ways that Arcadia has always been considered and interpreted, misleadingly, even in two paintings by Poussin, which I refer to in my paper. These in reality remind us that in Arcadia there is death too. Even the memory that the documents should help us to conserve is ineluctably bound to loss, dissemination, mutilation and uncertainty, and therefore must also face the presence of death also.

Archives↗
PubMedDate not supplied

[Video documentation in forensic practice].

The authors report in part 1 about their experiences with the Canon Ex1 Hi camcorder and the possibilities of documentation with the modern video technique. Application examples in legal medicine and criminalistics are described autopsy, scene, reconstruction of crimes etc. The online video documentation of microscopic sessions makes the discussion of findings easier. The use of video films for instruction produces a good resonance. The use of the video documentation can be extended by digitizing (Part 2). Two frame grabbers are presented, with which we obtained good results in digitizing of images captured from video. The best quality of images is achieved by online use of an image analysis chain. Corel 5.0 and PicEd Cora 4.0 allow complete image processings and analysis. The digital image processing influences the objectivity of the documentation. The applicabilities of image libraries are discussed.

Equipment Design↗
PubMed1996

A pain management documentation tool.

PURPOSE/OBJECTIVES: To describe the development, implementation, and evaluation of a tool to standardize assessment, monitoring, management, and documentation of acute and chronic pain in hospitalized patients. DATA SOURCES: A multidisciplinary hospital committee, nursing staff, a pain consultant, published standards, and hospital standards. DATA SYNTHESIS: A comprehensive pain flow sheet and pain protocol was developed to assess, monitor, document, and evaluate clients at risk for or with actual pain. The tool was designed to assess and document acute and chronic pain in patients with cancer. CONCLUSIONS: Based on an initial review of quality assurance indicators, the tool has demonstrated increased consistency in documentation of pain management activities. IMPLICATIONS FOR NURSING PRACTICE: The use of a pain assessment and management flow sheet with a pain protocol provides an organized, consistent approach that maximizes quality, cost-effective care.

Analgesics↗
PubMed1996

Navigating through a document-centered electronic medical record: a mock-up based on WWW technology.

Current WWW technology facilitates the development of "hypertext" applications. A hospital-wide study of users' requirements in France led to a document-centered approach to the patient Electronic Medical Record (EMR). In order to refine such a specification, and taking advantage of WWW technology, we have developed a running mock-up of a document-based EMR from an actual paper-based patient record. Synthesis documents were added and linked to original replicated paper documents to form a hypertextual EMR. The mock-up has been presented to health care professional boards to gather their remarks and wishes, and then enhanced accordingly. The current version reflects (part of) their requirements for an EMR, and is presented in this paper.

Clinical Medicine↗
PubMed1997

A comprehensive interdisciplinary chemotherapy teaching documentation flowsheet.

PURPOSE/OBJECTIVES: To describe the development and implementation of one approach to standardize and document interdisciplinary chemotherapy education for patients and families. DATA SOURCES: Cancer center interdisciplinary team. Oncology Nursing Society standards of care, clinical experience, and published literature. DATA SYNTHESIS: Because chart reviews of patient records demonstrated inconsistent chemotherapy education, a comprehensive chemotherapy curriculum pain was designed as a template for patient education. A flowsheet was developed to document use of the patient curriculum as well as other chemotherapy-related education materials. Patient chemotherapy curriculum included information regarding cancer and its treatment, adverse effects, and self-care measures and material about psychosocial and spiritual care. CONCLUSIONS: A standardized approach dramatically improved chemotherapy-related patient education as well as interdisciplinary documentation of patient education. The curriculum and the flowsheet are interdisciplinary and consistent with the patient and family education standards required by the Joint Commission on Accreditation of Health Care Organizations. IMPLICATIONS FOR NURSING PRACTICE: The combination of a patient chemotherapy curriculum and a documentation flowsheet saves time and standardizes content. Patient information is comprehensive and consistent, yet open to individual interpretation. Use of the flowsheet also has increased interdisciplinary collaboration, and the standardized curriculum has decreased redundancy between providers because all members of the interdisciplinary team know what is required and what information has been taught by whom.

Antineoplastic Agents↗
PubMed1997

[The Norwegian Patient Insurance System. Documentation of patient information and use of medical experts in cases of injuries].

Claims for compensation for surgical injuries submitted to the Norwegian System of Compensation for Injuries to Patients were analysed with respect to the written documentation of the case, patient information and the medical experts involved. Documentation of the indication for treatment, the surgical procedures and the injury were good, and acceptable in more than 90% of the case reports. Preoperative information on the patient was only documented in the report in 5% of the cases. There has been some discussion on the way in which medical experts used in the evaluation of patients claims are selected. In order to increase the legitimation of the medical experts we suggest that the Norwegian System of Compensation for Injuries to Patients and the Norwegian Board of Health should consider using the same set of rules for selecting experts. To improve the quality of patients' treatment and for security reasons, the System of Compensations of Injuries to Patients' data on documentation of patient information and categorized reports on the medical errors should be periodically reported to the hospitals.

Clinical Competence↗
PubMed1998

A qualitative analysis of the nursing documentation of post-operative pain management.

As part of trust-wide practice development project to improve post-operative pain management, a descriptive study was conducted in the orthopaedic directorate of a large teaching hospital in the north of England. Sixty-five patients were included in this prospective study. Patients were interviewed post-operatively about their pain experience, and present and worst pain scores were recorded. The nursing documentation relating to pain management was also transcribed and a content analysis of this nursing documentation is reported. Findings indicate that individual assessment of pain was poorly documented and that the nurses' record of the patient's post-operative pain experience differed from the patient report. Reliance on pharmacological methods of pain relief was evident and interventions to help patients cope with night time pain were rarely documented. The results are discussed in light of a theoretical framework for acute pain management and current research. Implications for practice are discussed and areas for further research are suggested.

Adult↗
PubMed1982

Critical evaluation of the toxicological documents produced for the authorization of drugs according to the Commission of the European Communities Directives.

The documents concerning the experimental safety evaluation of drugs are evaluated in France by an advisory board of the Ministry of Health which expresses an opinion on their accuracy, indispensable for the authorization of sale. The data reported here concern 95 documents examinated between 1978 and 1981. They are related: - To the form of presentation of the documents: 14 main kinds of defects are pointed out (lack of justification of the protocols, inadequate experimental data, etc.). - To the substance of the experiments: 21 main kinds of defects are emphasized (erroneous choice of the doses, poor clinical examination of the animals, etc.). In conclusion, a real effort to obtain a large and constructive exchange of information between all the parties concerned, the manufacturers, the experts, the Ministries of Health, must be continued.

Animals↗
PubMed2004

Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

Craniocerebral Trauma↗
PubMed1990

Requirements for the documentation of pharmacokinetic properties of antimicrobial agents.

Proper documentation of new antimicrobial drugs for governmental registration authorities includes extensive pharmacokinetic studies. Pharmacokinetics represents the bridge between the in vitro and in vivo phases of drug development. Both healthy human volunteers and patients must be studied, the former during the initial stages of the pharmacokinetic studies. The documentation should give information on the following: absorption from the gastrointestinal tract, bioavailability, pharmacokinetic model, impact of increasing doses (oral and intravenous), metabolism, routes and degree of elimination, interaction with food and other drugs, impact of the steady state, and serum protein binding. Basic pharmacokinetic parameters used are the serum half-life, clearance, distribution volume and dose dependence. The bioavailability of oral doses must be determined using the same dose sizes and subjects. Data on extravascular penetration should also be included in complete documentation. Key diseases in which the pharmacokinetics should be studied are reduced renal and liver function, heart failure, pregnancy, cystic fibrosis and intestinal diseases. The consequences of low age (e.g. newborns) and old age also require some attention.

Animals↗
PubMed2005

[Systematic drug documentation].

Medication histories as the most common way to document individual drug use provide a valuable database. Their main purpose is to check the patient's medication for so-called drug-related problems such as interactions, compliance problems, adverse drug reactions, and others. A second concern is to gain epidemiological evidence which increases the knowledge about benefits and risks of drugs including economic consequences. By referring to well-accepted principles of data protection, the documentation of drug use data has to be an essential part of complex care programmes which allows improvement of the individual drug therapy by reducing possible risks and increasing the therapeutic outcome of drug use more effectively. In addition, systematic drug documentation can be used to build structured databases which usually make use of prescription data. Given that principles of data protection, especially with regard to anonymity, are considered such databases provide an opportunity of data linkage with other health-related information such as health care services or number of sick leave days. Regardless of certain methodological limitations, these databases can also be used for health economics research and evaluation.

Computer Security↗