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At least 721 records · Page 40Linked to original sources
PubMed2002

[Evaluation of an information document about patients and transfusion].

OBJECTIVE: To evaluate the understanding of written information contained in the information sheet for patients intended to receive an homologous transfusion and to know their opinion about this document. TYPE OF THE STUDY: A prospective cohort survey carried out by people unrelated to clinical units and transfusion services. METHODS: A document divided in two parts, the first one summarized, the second detailed, was distributed to transfused adult patients. The patients were hospitalized in the general surgery and orthopedic wards of two hospitals and in the hematology and oncology wards of two different hospitals. A questionnaire was filled out in the presence of the inquirer. RESULTS: Sixty one subjects have been enrolled, among them 53 considered the information as adequate; 53 as comforting and neutral. 53 patients considered a written information as essential and 52 estimated that both part of the information sheet (summarized and detailed) were mandatory. Conversely, a more in depth investigation revealed there was a gap between patients statements and their true understanding. CONCLUSION: The value of a written information for the patients is confirmed by the study. In addition, patients were not generally worried by this information. The partition of the document has been appreciated. It is noteworthy that a gap exist between the patient's perception of the information and their actual level of understanding.

Adult↗
PubMed1997

Documenting life-support preferences in hospitalized patients.

PURPOSE: The purpose of this article was to determine the extent to which patients at high risk of hospital death who undergo cardiopulmonary resuscitation (CPR) have previously had their life support preferences addressed and documented. MATERIALS AND METHODS: We conducted a retrospective chart review of all patients older than 18 years of age hospitalized for more than 24 hours who sustained a cardiac arrest with attempted CPR at our tertiary care university teaching hospital during 1994 (n = 71). We searched all hospital charts specifying ICD-9 codes: Cardiac arrest, ventricular fibrillation, ventricular tachycardia, asystole, electromechanical dissociation, defibrillation, or CPR. Patients were selected if (1) they had a true cardiac arrest (abrupt cessation of spontaneous circulation) and (2) had attempted CPR or defibrillation. Patients were classified as "high risk" if they satisfied at least one of the following: modified prearrest morbidity index > or = 7, moderate/severe dementia, day 1 APACHE II score > 24 or > or = 4 dysfunctional organ systems. RESULTS: We searched 147 charts; of 71 patients meeting inclusion criteria, 53 were high risk. Of patients at high risk of sustaining a cardiopulmonary arrest during the index hospital admission, 3 (6%) had preferences addressed within the first 24 hours of hospitalization, 7 (13%) had delayed discussion of preferences before arrest, 23 (43%) had preferences addressed post arrest, and 20 (38%) had no documented discussions. Of the 23 high-risk patients initially surviving cardiac arrest, all were subsequently given "do not resuscitate" orders. Univariate analysis of factors associated with life-support discussion before cardiac arrest were previous cardiac arrest (OR, 5.9) and APACHE II score > 24 (OR, 1.1), although neither reached statistical significance. None of the 32 patients with a modified PAM index > or = 7 (32 of 71) survived hospitalization. Only 3 patients survived to hospital discharge. CONCLUSIONS: Early communication regarding life-support preferences is important in high-risk patients so that inappropriate or unwanted treatment is not implemented. Given that optimal care includes addressing and documenting life-support preferences in high-risk patients early in their hospitalization, this standard was infrequently met.

APACHE↗
PubMedDate not supplied

The effect of quality assurance on flight nurse documentation.

This study was developed to evaluate if a structured quality assurance program has an effect on nursing documentation. A randomized, retrospective audit of records was conducted from 1985 to 1989, and in November 1987, a structured QA program was initiated for flight nurses. Each chart was audited for completeness of 69 elements from seven categories: administrative information, patient history, physical exam, management plan, vital signs, medications and intravenous access. A comparison of audit results was conducted before and after the QA program was initiated. A total of 224 charts were audited, 123 before the QA program and 101 after. There was statistically significant improvement in 4 of 13 administrative, 5 of 7 history, 21 of 31 physical exam, 2 of 6 management, 2 of 2 vital signs, 0 of 4 medication, and 0 of 6 intravenous access elements. Twenty-five of 35 categories that did not show improvement had initial completion rates greater than 90 percent. The significant improvement in documentation by flight nurses after a formal QA program was initiated lead the authors to conclude that QA benefits air medical programs by providing a mechanism to improve documentation.

Aircraft↗
PubMed1999

[Quality assurance: the AO documentation at a peripheral hospital].

Follow-up of fracture treatment one year after surgery based on AO Documentation in a small, rural hospital in a region with many tourists is demanding. How many patients can be contacted and assessed at the one year follow-up? From 1.1.95 to 31.12.96 302 patients with 314 fractures were operated on and the results subsequently documented. 255 patients (84%) were assessed personally (221) or by an AO member or family doctor (34). 15 patients died before the appointment, 32 patients could not be contacted or their data was incomplete. To achieve this rate of follow-up, some internal organization in the hospital was necessary, as will be described in this paper. AO Documentation is an important tool for personal quality assurance, especially in small hospitals. Small hospitals might be interesting for the AO since their follow-up rate can be high due to a simple organization and a personal patient-doctor relationship.

Aged↗
PubMed1998

Guidelines for documentation of treatment efficacy for young children who stutter.

The pressing need to document treatment efficacy for young children who stutter is discussed. Guidelines for such documentation are suggested and illustrated. Measures for verifying treatment effects in four realms are delineated: (a) conditions of documentation, (b) dependent variables to be measured, (c) establishment of treatment integrity, and (d) verification of the relationship between treatment and outcome. Illustrations of the application of the suggested guidelines are presented for 2 children.

Child, Preschool↗
PubMed2003

School nurses' view of schoolchildren's health and their attitudes to document it in the school health record--a pilot study.

This study highlights school nurses' view of schoolchildren's health and their attitude to document it in the school health records. A strategic sample of 12 school nurses was interviewed. The interviews were semistructured and analysed with qualitative content analysis. The findings showed that the school nurses' viewed schoolchildren as physical healthy although they called attention to growing problems related to a changed lifestyle. Psychosocial ill-health was however increasing and the most common reason for visiting the school nurse was psychosomatic expressions. According to the nurses' descriptions, health was related to the individual, the school and the family situation. The family situation was mentioned as one of the most important factors of schoolchildren's health. The nurses described no problem to document schoolchildren's physical health. Ethical consideration, tradition, lack of time and the structure of the record were however factors that were said to hinder the documentation of the psychosocial health. In order to promote, protect and recover schoolchildren's health, more research is needed about how beliefs, experience, ethical consideration and resources influence the school nurse's daily work with schoolchildren's health.

Adult↗
PubMed2003

Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district.

The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.

Adult↗
PubMed2003

End-of-life intensive care unit decisions, communication, and documentation: an evaluation of physician training.

PURPOSE: The majority of patients dying in intensive care units (ICUs) do so after the forgoing of life-sustaining therapies (FLST). Communication between physicians, patients, and their families regarding the decision to FLST has not been evaluated in Israel. MATERIALS AND METHODS: All patients who had FLST in a general ICU were enrolled in the study. We evaluated whether physicians communicated and documented the FLST decisions with patients or the patients' families. We also assessed the effect of the physician's geographic place of training on communication behavior. RESULTS: Over a period of 8.5 months, 385 patients were admitted to a general ICU in Israel. Fifty-seven patients died or had FLST. Twelve of these 57 were excluded from the study. Thus, 45 (79%) patients had FLST and were enrolled in the study. All patients were deemed medically incompetent to make FLST decisions. In 24 (53%) patients, FLST was discussed with the family before the decision to forgo therapy. Discussion occurred later with 6 other families, who were unavailable at the time the FLST decision was made. In 15 patients, there were no discussions with families. American-trained physicians discussed FLST with 22 of 29 families initially and 5 other families later (93%), whereas the Eastern European-trained physicians discussed FLST with only 3 of 16 (19%) families (P <.001). Documentation of FLST was present in 26 (90%) patients of American-trained physicians and 8 (50%) patients of Eastern European-trained physicians (P <.001). CONCLUSIONS: FLST is common in an Israeli ICU. Patients are not medically competent to make FLST decisions. American-trained physicians discuss and document FLST more often than Eastern European-trained physicians.

Aged↗
PubMed2001

[Evaluation of environmental medicine documentation in Schleswig-Holstein 1995-1999].

Physicians qualified in environmentally related disorders due to their participation in special training courses in the Federal State of Schleswig-Holstein (Germany) used a standardised questionnaire to report on their environmental medicine related cases. The course of the illness, if known, has been documented on a separate data sheet. During the period from 1995-1999 916 cases and 508 courses of illness were assessed. The environmental factors/toxicants of exposure most frequently documented by the 85 participating physicians and found to be related to symptoms of illness were biocides (mainly insecticides used indoors for pest control (32%), moulds (27%), dental amalgam (22%), solvents/volatile organic compounds (21%) and formaldehyde (16%), respectively. In 42% of the documented cases an exposure to more than one environmental factor/toxicant was registered. Age distribution, gender, location of exposure as well as the symptoms of illness of the patients were found to be dependent on the type of exposure. Cessation of exposure to harmful substances/environments was achieved in 54% of those cases where information regarding the course of the illness was given. In 65% of these cases recovery was reported and 30% recovered partially. In those cases where a cessation of exposure could not be achieved or was not complete, no or only partial recovery was mostly reported. From these results it may be concluded that research work on environmentally related disorders should be enforced in order to prevent unnecessary illness and to lower the public health system expenditure.

Adolescent↗
PubMed2002

[Problems encountered during the installation of an automated anesthesia documentation system (AIMS)].

Problems encountered during the installation and introduction of an automated anaesthesia documentation system are discussed. Difficulties have to be expected in the area of staff training because of heterogeneous experience in computer usage and in the field of online documentation of vital signs. Moreover the areas of net administration and hardware configuration as well as general administrative issues also represent possible sources of drawbacks. System administration and reliable support provided by personnel of the department of anaesthesiology assuring staff motivation and reducing time of system failures require adequately staffed departments. Based on our own experiences, we recommend that anaesthesiology departments considering the future installation and use of an automated anaesthesia documentation system should verify sufficient personnel capacities prior to their decision.

Anesthesia Department, Hospital↗
PubMed2002

[An outline for the standard graphical documentation of pathological macular findings].

BACKGROUND: Accurate documentation and follow-up of pathological findings of the macula require graphical methods for clinical evaluation. METHODS: Symbols describing and identifying different findings of the macula were evolved. A pattern for the standardised representation of the macular region -- with size and distribution of different areas -- was also developed. RESULTS: Use of different symbols supported by a standard pattern of the macula as background simplifies documentation of pathological macular findings. CONCLUSIONS: Graphical documentation of pathological macular findings allows simple, inexpensive and standardised assessment of such findings.

Computer Graphics↗
PubMed1991

[Observations on documentation and recording of audiometry results].

The article deals with various aims of documentation of results in audiometry and the influence of audiometer design on the outcome or execution of documentation and graphical representations. Recorded data should always be complete and unequivocal in respect of the intended aims. Didactic purposes and proof of plausibility may require more data than just the final results. External users of audiograms may require additional legends. Documentation by computer can be only as variable as the scope of the equipment permits. It seems that at the present time manual recording still has its merits.

Audiometry↗
PubMed1981

[Cooperative documentation of childhood malignancies (author's transl)].

Since January 1980 a nationwide documentation of childhood malignancies is performed in the FRG. The cooperative documentation system is supported by the Stiftung Volkswagen-werk and centralized at the Institut für Medizinische Statistik und Dokumentation (IMSD) of the university of Mainz. During the first year of the project the incidence of 1002 malignancies has been reported from a total of 62 hospitals with a still increasing number of cooperating centers. The documentation scheme is based on recommendations of the ADT (working group of tumor centers in the FRG) which are in accordance with international recommendations by the W.H.O., U.I.C.C. etc. A newly diagnosed malignancy is reported by a short standardized form to the IMSD which in turn sends out tumor-specific questionnaires of modular structure for obtaining relevant baseline variables. Patient follow-up is achieved by obtaining the status of all patients at least twice a year which is sent in a condensed format to the IMSD. Besides obtaining basic epidemiological data the system will provide detailed analyses on the course of the different malignancies, allow comparisons between different disease groups as well as different hospitals and will serve as a recruiting basis for controlled clinical trials.

Age Factors↗
PubMed1989

[Classification and documentation of vulvar changes: organization of a data bank by personal computer].

We developed a simple menu driven database on a personal computer for classification and documentation of vulvar lesions (IBM-PC, dBaseII). Vulvar lesions were classified according to morphological appearance: red, white, dark, ulcer, small tumor (less than 1 cm), large tumor. The data for each category were entered in multiple choice form or as free text and stored in a separate database file. Overlap between categories was observed in vulvar intraepithelial neoplasia, invasive carcinoma and between large and small tumors. For each category an automated table of the frequencies of the different diagnoses is provided, individual patients and variables can easily be accessed through the database query language. We used the database system in the gynecological outpatient clinic of our department during 6 months and were able to document 117 patients with vulvar lesions. In our experience, the database system permits complete documentation according to clinical criteria of all vulvar lesions seen in gynecological practice.

Diagnosis, Differential↗
PubMedDate not supplied

[Basic differential documentation as conditio sine qua non for effective quality assurance].

The quality check in medicine increases not at all by judges order. This contribution shows in what point of medical-documentation quality check must begin, if she should be effective. Some examples explain, that only a discriminated and a by specialist examined basic documentation is able to give us valid statistics of clinical data. Some results of our quality checked basis documentation were presented too.

Cross-Sectional Studies↗
PubMedDate not supplied

[Basic medical documentation with ID DIACOS as an instrument for quality assurance].

Standardized methods and instruments of medical documentation are prerequisites for quality assurance in medicine. Support for quality assurance measures at present can be attained by the programme systems ID DIACOS (encoding of diagnoses into ICD-9 and procedures into ICPM-GE) for daily clinical routine documentation. Administrative statistics, e.g. the L1-statistics of diagnoses according to section 16 Federal Statutory Instrument on Hospital Care Rates (BPflV) can be compiled without waste by aggregation. Supplementations of the programme system are planned caused by the introduction of new forms of Hospital reimbursement with changed classification patterns. An increasing need for computer-aided encoding will also result by the implementation of new classifications, e.g. ICD-10 and by the requirements concerning a scientific basic documentation (Selbmann, 1990; Mau, 1990) based partly on nomenclatures. The connection of the programme systems ID DIACOS and SNOMED (empirical and morphological analysis of medical texts) is possible and will be carried out (Hultsch, Diekmann, Ruhl, 1990).

Diagnosis↗
PubMedDate not supplied

[Orthopedic basic documentation: requirements of diagnostic statistics and results in Göttingen university clinics].

For the first time the revised "Bundespflegesatzverordnung" (Federal Statutory Instrument on Hospital Care Rates) of 1985 has ordered all the hospitals in the F.R.G. to prepare annual statistics of diagnoses giving as part of the anonymous hospital statistics an overview about the medical variety of inpatients and enabling scientific evaluation of cases. The most important documentation items are patient's age, duration of stay, main diagnosis encoded according to ICD-9, and operation characteristic (whether or not any of the operations was carried out because of the main diagnosis). The computerized Goettingen documentation comprises all 15 items of the Minimum Basic Data Set of the European Communities and a few other additional details. The result is a comprehensive and in many directions useful medical documentation for which examples are given.

Arthritis, Rheumatoid↗
PubMedDate not supplied

[DocuMed--a personal computer program system for basic documentation and ICD statistics based on SNOMED].

Of the different medical classification systems ICD only has endured on the long time, and through the german government regulations from 1985 (Bundespflegesatzordnung) ICD has become a must to all hospital departments for administration purposes. As a clinical and scientific system for encoding of diagnosis and treatment procedures ICD has been proved to be of minor suitability. SNOMED, a medical classification system derived from a pathological description of diseases seemed first to fulfill all the wishes clinicians have; but the very little use over the 12 years since its publication demonstrates its poor acceptance. This might be due to the time consuming and lavish procedure of documentation in SNOMED, as entries have to be made in 7 categories. DocuMed, which is a microcomputer program and database on the one hand and a medical classification system on the other, seems to provide interesting features. For minimal documentation it only needs entries in the category of diagnosis, a term not present in SNOMED; for more detailed documentation requirements DocuMed provides similar categories as SNOMED with references to the latter and to ICD.

Bone Diseases↗