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At least 703 records · Page 39Linked to original sources
PubMed2003

[Standardized documentation procedure as a basis for improvement of process quality of treatment in psychiatric hospitals].

A standardized documentation system is presented for detailed description and analysis of treatment procedure for psychiatric inpatients. In the first step of a pilot study limited to patients with depressive syndromes at the Department of Psychiatry, University of Mainz, for each subject the clinical status was assessed weekly using psychopathological ratings and depicted in its temporal course along with therapeutic activities. Visualization of the treatment process turned out to be useful for everyday work by supporting the application of practice guidelines for clinical decisions. Beyond optimization of the individual treatment process, aggregation of the data also allows global assessment of treatment processes in the clinic. Thus, in addition to established basic documentation, the presented documentation procedure allows the development of a powerful quality management system in psychiatric clinics, due to its process orientation. Moreover, in psychiatric care research, it is an adequate basis for evaluating the effectiveness and efficiency of treatment procedures.

Adult↗
PubMed1995

[Standardized documentation of patho-anatomic findings using ADT (Association of German Tumor Centers) tumor forms for malignancies of the mouth, jaw and face (version III)].

The documentation form for pathohistologic findings (version III) for tumors of the maxillofacial region is presented. It is part of the site-specific documentation of the German Association of Tumor Centers (ADT). Its handling is explained by instructions which are based on the ICD-O classification and the TNM system. The prognostic relevance of the standardized documentation has already been proven by various histomorphologic investigations concerning oral and oropharyngeal cancer. By means of a multicentric observational study the German Austrian Swiss co-operative group DOSAK will develop a new prognostic model for oral and oropharyngeal cancer.

Documentation↗
PubMed2000

[Documentation concepts in MedNet-Rheuma (competence network "Inflammatory-rheumatic systemic diseases")].

Concepts of documentation rely not only on the contents required and technical demands, but the procedures covered and in medical applications especially security aspects are also matters of critical concern. Even though the need for effective documentation (i.e., adequate in content, availability, feasibility and easy to retrieve analysis) is not a question, tasks and aims (for example, quality of patient care) deserve attention and establishing efforts have to be analyzed regarding their structural and personal prerequisites and implications before particular tools for documentation can be developed.

Computer Security↗
PubMed2026

Time to subsequent therapy (TTST) as an endpoint in clinical studies: development of standardized documentation of subsequent therapy through systematic literature review, expert interviews, and Delphi survey.

BACKGROUND: The endpoint Time to Subsequent Therapy (TTST) is an intermediate endpoint used in research and regulatory assessments. TTST denotes initiation of subsequent therapy and is a clearly definable, clinically relevant event for healthcare professionals. However, it has not been systematically established to which extent TTST is subjectively meaningful to patients. The objective of this study was to define TTST as a patient-relevant intermediate endpoint. METHODS: The study examined five oncological indications (breast cancer, prostate cancer, melanoma, multiple myeloma, and non-small cell lung cancer) using a systematic literature review, analysis of case report forms used in international randomized controlled trials, review of German Federal Joint Committee (G-BA) documents, semi-structured interviews and a two-stage Delphi survey with healthcare professionals, patients, and relatives. RESULTS: A total of 35 individuals participated in qualitative interviews. Most of them rated TTST as particularly significant. The Delphi Survey included 264 interviewees in round one, and 117 in round two. Patient-relevance of TTST was confirmed by 81% of respondents (95% confidence interval 76%, 85%). Nine treatment scenarios that justify TTST were identified. To capture patient-relevance, prospective collection of reasons for and consequences of therapy change are required. A checklist with standardized response formats plus free-text fields was developed: a comprehensive master checklist for flexible, complete documentation and a short version focused on therapy change-specific items. CONCLUSIONS: TTST is an intermediate endpoint whose systematic documentation of characteristics demonstrating patient-relevance can be standardized in research and clinical practice using the developed checklists.

Humans↗
PubMed2006

Function approximation and documentation of sampling data using artificial neural networks.

Biodiversity studies in ecology often begin with the fitting and documentation of sampling data. This study is conducted to make function approximation on sampling data and to document the sampling information using artificial neural network algorithms, based on the invertebrate data sampled in the irrigated rice field. Three types of sampling data, i.e., the curve species richness vs. the sample size, the curve rarefaction, and the curve mean abundance of newly sampled species vs.the sample size, are fitted and documented using BP (Backpropagation) network and RBF (Radial Basis Function) network. As the comparisons, The Arrhenius model, and rarefaction model, and power function are tested for their ability to fit these data. The results show that the BP network and RBF network fit the data better than these models with smaller errors. BP network and RBF network can fit non-linear functions (sampling data) with specified accuracy and don't require mathematical assumptions. In addition to the interpolation, BP network is used to extrapolate the functions and the asymptote of the sampling data can be drawn. BP network cost a longer time to train the network and the results are always less stable compared to the RBF network. RBF network require more neurons to fit functions and generally it may not be used to extrapolate the functions. The mathematical function for sampling data can be exactly fitted using artificial neural network algorithms by adjusting the desired accuracy and maximum iterations. The total numbers of functional species of invertebrates in the tropical irrigated rice field are extrapolated as 140 to 149 using trained BP network, which are similar to the observed richness.

Algorithms↗
PubMed2005

Chart documentation by general physicians of the glaucoma medications taken by their patients.

PURPOSE: To estimate the frequency of documentation of glaucoma medications by primary care physicians. DESIGN: Cross-sectional, observational study. METHODS: The general medical records of 100 patients of one glaucoma specialist were reviewed. We recorded whether the mention of eyedrops appeared in the medical record. RESULTS: The median number of glaucoma medications used was 2.5 (range 1 to 5). Fifty-five (55%, 95% confidence interval: 45%-65%) of the medical records of the primary physicians mentioned eyedrops. Alpha-agonists were statistically less frequently documented (13%) in the general medical record than beta-adrenergic blockers (47%) and prostaglandins (44%). CONCLUSION: Almost half of the charts of these primary physicians had no documentation of any eyedrop use by their patients with glaucoma. An important step in reducing drug-induced side effects and interactions with other medications would be better recognition by primary physicians of the ophthalmic drugs used by their patients.

Adult↗
PubMed2005

TERMTrial--terminology-based documentation systems for cooperative clinical trials.

Within cooperative groups of multi-center clinical trials a standardized documentation is a prerequisite for communication and sharing of data. Standardizing documentation systems means standardizing the underlying terminology. The management and consistent application of terminology systems is a difficult and fault-prone task, which should be supported by appropriate software tools. Today, documentation systems for clinical trials are often implemented as so-called Remote-Data-Entry-Systems (RDE-systems). Although there are many commercial systems, which support the development of RDE-systems there is none offering a comprehensive terminological support. Therefore, we developed the software system TERMTrial which consists of a component for the definition and management of terminology systems for cooperative groups of clinical trials and two components for the terminology-based automatic generation of trial databases and terminology-based interactive design of electronic case report forms (eCRFs). TERMTrial combines the advantages of remote data entry with a comprehensive terminological control.

Clinical Trials as Topic↗
PubMed2004

Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey.

UNLABELLED: Computer-based software to record histories, physical exams, and progress or procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. The functionality of CBD systems has remained static over the past 30 years, which may have contributed to the limited adoption of these tools. Early users of this technology, who have tried multiple products, may have insight into important features to be considered in next-generation CBD systems. OBJECTIVE AND METHODS: We conducted a cross-sectional, observational study of the clinical working group membership of the American Medical Informatics Association (AMIA) to generate a set of features that might improve adoption of next-generation systems. The study was conducted online over a 4-month period; 57% of the working group members completed the survey. RESULTS: As anticipated, CBD tool use was higher (53%) in this population than in the US physician offices. The most common methods of data entry employed keyboard and mouse, with agreement that these modalities worked well. Many respondents had experience with pre-printed data collection forms before interacting with a CBD system. Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians (all P < 0.001). Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate billing information. CONCLUSIONS: The latest generation of CBD systems is being used successfully by early adopters, who find that these tools confer many advantages over the approaches to documentation that they replaced. These users provide insights that may improve successive generations of CBD tools. Additional surveys of CBD non-users and failed adopters will be necessary to provide other useful insights that can address barriers to the adoption of CBD by less computer literate physicians.

Adult↗
PubMed2006

Low-cost conversion of the Polaroid MD-4 land camera to a digital gel documentation system.

A simple, inexpensive design is presented for the rapid conversion of the popular MD-4 Polaroid land camera to a high quality digital gel documentation system. Images of ethidium bromide stained DNA gels captured using the digital system were compared to images captured on Polaroid instant film. Resolution and sensitivity were enhanced using the digital system. In addition to the low cost and superior image quality of the digital system, there is also the added convenience of real-time image viewing through the swivel LCD of the digital camera, wide flexibility of gel sizes, accurate automatic focusing, variable image resolution, and consistent ease of use and quality. Images can be directly imported to a computer by using the USB port on the digital camera, further enhancing the potential of the digital system for documentation, analysis, and archiving. The system is appropriate for use as a start-up gel documentation system and for routine gel analysis.

DNA↗
PubMed2006

Physician documentation of neonatal risk assessment for perinatal infections.

Charts of newborn infants were reviewed for documentation of maternal risk factors and prenatal screening test results. Physician documentation was incomplete in most infants. Nearly half of all infants were discharged without documentation regarding maternal status of hepatitis B, syphilis, and group B streptococcus. These lapses in newborn assessment have a potential for significant medical errors.

Adult↗
PubMed2006

Reliability of clinician-based (GRBAS and CAPE-V) and patient-based (V-RQOL and IPVI) documentation of voice disorders.

This study examined the reliability of two methods for documenting voice quality by clinicians and compared the methods for documenting patients' perceptions of voice quality. It involved a prospective reliability study and a retrospective chart review. Reliability of two clinician-based voice assessment protocols-Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) and Consensus Auditory Perceptual Evaluation-Voice (CAPE-V)-was evaluated. These two protocols were then compared after use in voice assessments of 42 males and 61 females performed by a certified speech-language pathologist specializing in the assessment of voice disorders. In addition, two patient-based scales (Voice Related Quality of Life, or V-RQOL, and Iowa Patient's Voice Index, or IPVI) obtained from the same patients were compared with each other and with the clinician-based scales. Reliability of clinicians' ratings of overall severity of dysphonia using GRBAS and CAPE-V scales was very good (r>0.80). Agreement between V-RQOL Total scores and IPVI ratings of the patient's perceptions of impact of dysphonia was less strong (Spearman's r=-0.76). There was relatively weak agreement between patient-based and clinician-based scales. Clinician's perceptions of dysphonia appeared to be reliable and unaffected by rating tool, as indicated by the high level of agreement between the two rating systems when they were used together. The CAPE-V system appeared to be more sensitive to small differences within and among patients than the GRBAS system. The V-RQOL and IPVI approaches to documenting patient's perceptions of dysphonia agreed less well possibly due to differences in patient dependence on voice and on interpretation of the rating tool items. The differences between clinician-based and patient-based data support the conclusion that clinicians and patients experience and consider dysphonia very differently.

Adolescent↗
PubMed2001

ISO and CEN documents on quality in medical laboratories.

The forthcoming international standard ISO 15189 "Quality management in the medical laboratory" is a document of great importance for the development of quality systems and accreditation for medical/clinical laboratories. For the first time, there will be an internationally recognized standard designed specifically for the accreditation of medical laboratories. The document takes into account the special requirements imposed by the medical environment and by the essential contribution of the medical laboratory service to patient care. It recognizes that medical laboratories must provide not only testing of patient samples, but also advisory, interpretative and educational services. A further document, still in draft form (ISO/DIS 15190), deals with safety management for medical laboratories. ISO 15189 (and probably 15190 also) are expected be adopted by CEN as a European Standard (EN).

Accreditation↗
PubMed2004

Digital video for the documentation of colonoscopy.

BACKGROUND: The aim of this study was to determine whether digital video is suitable for the documentation of colonoscopy. Standards are required for the visual documentation of endoscopic findings and to optimize image quality while limiting file size and bandwidth requirements. METHODS: Video recordings of colonoscopy procedures were encoded using a common video compression method at selected data rates and resolutions. Twelve reviewers were selected, each of whom was assigned 8 video review sessions, each consisting of 5 colonoscopy procedures. The reviewers rated the following: level of confidence that the cecum was demonstrated, subjective quality of the video compared with actual videocolonoscopy, and whether the video was of "diagnostic quality." RESULTS: Reviewers were confident that the cecum was demonstrated in all cases except at the lowest data rate. The 1.0 Mbps standard interchange format video provided an optimal balance between quality and file size. CONCLUSIONS: For the documentation of colonoscopy, 1.0 Mbps is acceptable and results in a file size of 7.5 Mbytes/min, which is manageable for most modern hospital and telehealth networks.

Colonoscopy↗
PubMed1989

Physicians' do-not-resuscitate decisions and documentation in a community hospital.

Physician documentation of the participants in do-not-resuscitate (DNR) decisions and the equitability of DNR decisions were studied in a 450-bed community hospital in San Francisco. All 333 patients who received written DNR orders and the 108 physicians who made DNR decisions were studied. Of the sampled records, 45% contained no documentation of who participated in the DNR decision. Only 38% of the documented records showed that patients were involved in the DNR decision. In the remaining cases (62%), families were involved as surrogate decision makers. The rate of physicians' DNR decision-making varied according to physician specialty: Oncologists, neurologists, gastroenterologists, and pulmonologists had the highest rates, while surgeons, cardiologists, and general practitioners had the lowest.

Decision Making↗
PubMedDate not supplied

Follow-up consultation billing and documentation.

Frequently, bills are not submitted for follow-up visits for patients who have been evaluated psychiatrically on medical-surgical services. There often is confusion regarding which procedure codes are most appropriate to use in billing. To help the consultant understand the documentation requirements for various procedure codes, information from several sources was synthesized and distilled. This paper should help minimize documentation errors and maximize reimbursement for clinical services. The authors have reviewed available billing choices, and clarified the documentation requirements for different procedure codes according to Medicare regulations.

Accounting↗
PubMed2003

Improving decision-making and documentation relating to do not attempt resuscitation orders.

INTRODUCTION: Do not attempt resuscitation (DNAR) decision-making and recording in case notes can be poor. We have audited current practices pertaining to DNAR orders in a district hospital before and after the introduction of a standardised order form (SOF). METHODOLOGY: DNAR decisions in medical case notes were audited before and after the introduction of a SOF. All aspects of the decision were scrutinised against recommended guidelines (BMA/RCN/RC (UK) London: BMA, 1999). RESULTS: Case notes of 156 patients were examined. A total of 62 (39.7%) had combined case note and SOF documentation (Gp1), while 94 (60.3%) had case note documentation only (Gp2). Some 61/62 (98.4%) of DNAR indications in Gp1 were in accordance with guidelines versus 81/94 (86.2%) in GP2 (P<0.01) and 50/62 (80.6%) of decisions were reviewed in GP1 versus 36/94 (38.3%) in GP2 (P<0.001). More decisions were authorised by consultants in GP1 (56/62 (90.3%) vs. 35/94 (37.2%) P<0.001) and had active patient participation (9/62 (14.5%) vs. 1/94 (1.1%) P<0.001) compared with Gp2. CONCLUSION: Documentation of DNAR decisions in medical case notes is poor. Standardised order forms, based on recommended national guidelines that complement case note entries, improve the process and recording of this sensitive decision.

Aged↗
PubMed1997

Correlation of patient entry rates and physician documentation errors in dictated and handwritten emergency treatment records.

This study was designed to examine the relationship between patient entry rates (a measure of physician work load) and documentation errors/omissions in both handwritten and dictated emergency treatment records. The study was carried out in two phases. Phase I examined handwritten records and Phase II examined dictated and transcribed records. A total of 838 charts for three common chief complaints (chest pain, abdominal pain, asthma/chronic obstructive pulmonary disease) were retrospectively reviewed and scored for the presence or absence of 11 predetermined criteria. Patient entry rates were determined by reviewing the emergency department patient registration logs. The data were analyzed using simple correlation and linear regression analysis. A positive correlation was found between patient entry rates and documentation errors in handwritten charts. No such correlation was found in the dictated charts. We conclude that work load may negatively affect documentation accuracy when charts are handwritten. However, the use of dictation services may minimize or eliminate this effect.

Documentation↗