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PubMed2002

Intranet-based safety documentation in management of major hazards and occupational health and safety.

In the European Union, Council Directive 96/82/EC requires operators producing, using, or handling significant amounts of dangerous substances to improve their safety management systems in order to better manage the major accident potentials deriving from human error. A new safety management system for the Viikinmäki wastewater treatment plant in Helsinki, Finland, was implemented in this study. The system was designed to comply with both the new safety liabilities and the requirements of OHSAS 18001 (British Standards Institute, 1999). During the implementation phase experiences were gathered from the development processes in this small organisation. The complete documentation was placed in the intranet of the plant. Hyperlinks between documents were created to ensure convenience of use. Documentation was made accessible for all workers from every workstation.

Computer Communication Networks↗

PubMed1995

Optimal production of biological documentation: the JAM format.

The current environment for providing documentation for users in molecular biology frequently requires written information for both printed and electronic media. The JAM. (Just Another Metafile) Format requires that only a single file of text is written. This is, then, processed by the jam program which converts this text to a document set which is suitable for on-line documentation in the hypertext mark-up language (HTML) of the World Wide Web system. For printed output, the jam program can produce either text in wordprocessor-ready Rich Text Format (RTF), or source code for the LaTEX typesetting system. The latter allows for professional text layout and can generate, amongst other formats, postscript files to be printed on a variety of devices.

Documentation↗

PubMed1984

Documentation of care and prospective payment. One hospital's experience.

Hospitals are now being reimbursed by Diagnosis Related Group (DRG) for Medicare patients. The Johns Hopkins Hospital has worked successfully under this system for the past 5 years, with cost increases being maintained well below the national average. Allowable revenue varies considerably by diagnosis depending on such factors as secondary diagnoses, procedure, and patient age. Failure to document accurately may result in substantial loss of hospital income. More worrisome is the use of data by outside agencies to evaluate quality of care. Recent reports of mortality rates for surgery in Maryland hospitals and of permanent pacemaker use are illustrative. Conclusions were inaccurate because of inadequate documentation of diagnoses and procedures by physicians and inaccurate coding by quality assurance coordinators. Surgeons need to be aware that in the prospective payment era, accurate and complete documentation is essential and that their data are likely to be used for purposes other than monitoring fiscal performance.

Abstracting and Indexing↗

PubMedDate not supplied

Defensible documentation using the endoscopy pathway.

Complete, defensible documentation in a busy endoscopy unit can be elusive. Quick turnaround time, impatient physicians, and add-on and emergent cases all contribute to chaotic days. The endoscopy pathway provides a guided path for succinct documentation by the healthcare worker. A scoring system is initiated on admission. Assessment parameters clearly define scores for vital signs, level of consciousness, abdominal status, pain, safety, and mobility. Scores can be scanned quickly and compared by the nurse to identify significant changes in each patient. Documentation is timely, communicative, and complete. The endoscopy pathway is illustrated by a case study. It reflects patients' progress throughout their stay in the GI unit from admission to discharge. The implementation process of this innovative chart form is presented.

Critical Pathways↗

PubMed2002

Development of a handheld computer documentation system to enhance an integrated primary care clerkship.

Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.

Clinical Clerkship↗

PubMed2003

Heart transplant patient teaching documentation.

Appropriate documentation of pre- and post-heart transplantation patient teaching has become increasingly challenging for the clinical nurse specialist (CNS) due to an increase in volume of referrals for heart transplantation evaluation, co-morbidities of those seeking transplant, complexity of the information that must be provided to candidates, demands by the Joint Commission on Accreditation of Health Care Organizations, and the compressed time for teaching, especially in the post-transplant hospitalization period. No heart transplant patient teaching documentation format was found in the literature that assisted us in overcoming these new demands. Using a center-developed Pre- and Post-Heart Transplant Patient Teaching Record, we describe a hypothetical case study to illustrate successful documentation by the CNS and the transplant team of the patient teaching plan of care.

Documentation↗

PubMedDate not supplied

Measuring the domain completeness of the Nursing Interventions Classification in parish nurse documentation.

As the healthcare industry moves toward automating the patient record, care providers have been challenged to capture their domain of practice in a computerized format. Nurses have responded by developing a number of American Nurses Association (ANA) recognized nursing standardized terminologies. This study measured the domain completeness and uses of one such terminology, the Nursing Interventions Classification (NIC), within the specialty of parish nursing, a spiritually focused, community-based practice. Documentation samples from 170 health records submitted by 13 parish nurses in 7 sites across the country, stratified by urban, suburban, and rural sites were used. The nursing interventions that were documented in 1607 unique interactions in these charts were mapped into NIC using standardized mapping procedures. Intercoder reliability was assessed, with a final kappa of 0.92 (93% agreement) and code-recode reliability with a kappa of 0.72 (74% agreement). Overall, 93% of the 3059 interventions mapped into NIC. Recommended modifications in existing NIC labels and additional NIC labels are presented. The results suggest that NIC supports the documentation of parish nursing practice and has the capability of capturing the spiritual dimension of care.

Attitude of Health Personnel↗

PubMedDate not supplied

A process for consolidation of redundant documentation forms.

Forms capturing redundant data can lead to duplicate documentation. This can be a source of patient and staff frustration, as well as data errors. The definition of a process aimed at examining the data captured on forms documenting similar aspects of patient care is necessary to avoid this problem of duplicate documentation. A data-driven systematic process for consolidation of the multiple redundant forms used in various patient care areas across a healthcare delivery system is proposed and tested using the 21 intake forms currently used by a regional Health Maintenance Organization (HMO). The analytic and subsequent reporting processes used in this project provide a systematic method of forms consolidation that can be applied to other settings.

Abstracting and Indexing↗

PubMedDate not supplied

Electronic health records documentation in nursing: nurses' perceptions, attitudes, and preferences.

A descriptive study of 100 nursing personnel at a large Magnet hospital in Southwest Florida was conducted to assess their needs, preferences, and perceptions associated with Electronic Health Record (EHR) documentation methods. Nurses' attitudes about the use of EHRs and their perceived effects on patient care were assessed. The five-item, Likert-type attitude scale explained 54% of the variance in attitude scores and demonstrated sound construct validity and internal consistency (r = 0.77). More than one third, 36%, perceived that EHRs had resulted in a decreased workload. The majority of nurses, 64%, preferred bedside documentation but reported that environmental and system barriers often prevent EHR charting at the bedside. Overall, 75% of nurses thought EHRs had improved the quality of documentation and 76% believed electronic charting would lead to improved safety and patient care. Nurses with expertise in computer use, 80%, had a more favorable attitude toward EHRs than those with less expertise. Results have been used to implement clinical system changes.

Adult↗

PubMedDate not supplied

Documentation with MDS Section M: Skin Condition.

The Minimum Data Set is designed to be the assessment instrument used in all long-term-care facilities receiving federal funds for Medicare and Medicaid. However, Section M: Skin Condition is one of the most challenging sections to complete when trying to match the Minimum Data Set documentation with the true clinical picture. If wounds are not adequately assessed and documented, outcomes of care cannot be evaluated, and treatment and prevention plans will be inadequate. This may result in less than optimal outcomes and possible lawsuits for inadequate care against both the caregiver and facility. The purpose of this article is to provide examples of medical record documentation necessary to support the Minimum Data Set assessment.

Documentation↗

PubMed2001

Digital camera documentation system for facial nerve outcome assessment.

OBJECTIVE: To describe the use of a digital camera to document facial nerve function after skull base surgery. SETTING: Patients undergoing skull base surgery at a tertiary care otologic and neurotologic clinic were used in the study. INTERVENTIONS: None. RESULTS: A digital camera system provided still images and a video strip lasting less than a minute to document facial nerve motion. CONCLUSIONS: An inexpensive digital camera system can be used to capture still and moving images of facial nerve function on a floppy disk. The images can then be transferred to compact disks for storage of many patient files. Such a system allows documentation for research, exchange of data between offices, and patient education, and it can be used for medical-legal purposes among other uses.

Documentation↗

PubMed1998

Chart documentation: far reaching concerns.

The documentation of patient care is a critical nursing function. In addition to confirming that the nurse has practiced within the standards of care, the documentation is intensely scrutinized by those making payment and legal decisions. With the stroke of a pen or the tap of a keyboard the nurse records a fact or observation that will forever be a part of the data base. That data base may be used to determine benefits, allocate resources, settle legal arguments and even weigh criminal justice. Charting on the patient's record is both a privilege and a responsibility. It is not to be taken lightly. Every effort should be made to write from the perspective of a neutral reporter. The scope of documentation should be comprehensive and relevant. Observations should include the realms of psychosocial and emotional concerns as well as the physical. It is not necessary to make judgements or draw conclusions about the observations charted. It is enough to record pertinent assessments, actions and outcomes. It is from a database with these characteristics that we may be assured we are practicing in an ethical and responsible manner.

Documentation↗

PubMed2004

Machine printed text and handwriting identification in noisy document images.

In this paper, we address the problem of the identification of text in noisy document images. We are especially focused on segmenting and identifying between handwriting and machine printed text because: 1) Handwriting in a document often indicates corrections, additions, or other supplemental information that should be treated differently from the main content and 2) the segmentation and recognition techniques requested for machine printed and handwritten text are significantly different. A novel aspect of our approach is that we treat noise as a separate class and model noise based on selected features. Trained Fisher classifiers are used to identify machine printed text and handwriting from noise and we further exploit context to refine the classification. A Markov Random Field-based (MRF) approach is used to model the geometrical structure of the printed text, handwriting, and noise to rectify misclassifications. Experimental results show that our approach is robust and can significantly improve page segmentation in noisy document collections.

Algorithms↗

PubMed2005

Artificial neural networks for document analysis and recognition.

Artificial neural networks have been extensively applied to document analysis and recognition. Most efforts have been devoted to the recognition of isolated handwritten and printed characters with widely recognized successful results. However, many other document processing tasks, like preprocessing, layout analysis, character segmentation, word recognition, and signature verification, have been effectively faced with very promising results. This paper surveys the most significant problems in the area of offline document image processing, where connectionist-based approaches have been applied. Similarities and differences between approaches belonging to different categories are discussed. A particular emphasis is given on the crucial role of prior knowledge for the conception of both appropriate architectures and learning algorithms. Finally, the paper provides a critical analysis on the reviewed approaches and depicts the most promising research guidelines in the field. In particular, a second generation of connectionist-based models are foreseen which are based on appropriate graphical representations of the learning environment.

Algorithms↗

PubMed2004

Multioriented and curved text lines extraction from Indian documents.

There are printed artistic documents where text lines of a single page may not be parallel to each other. These text lines may have different orientations or the text lines may be curved shapes. For the optical character recognition (OCR) of these documents, we need to extract such lines properly. In this paper, we propose a novel scheme, mainly based on the concept of water reservoir analogy, to extract individual text lines from printed Indian documents containing multioriented and/or curve text lines. A reservoir is a metaphor to illustrate the cavity region of a character where water can be stored. In the proposed scheme, at first, connected components are labeled and identified either as isolated or touching. Next, each touching component is classified either straight type (S-type) or curve type (C-type), depending on the reservoir base-area and envelope points of the component. Based on the type (S-type or C-type) of a component two candidate points are computed from each touching component. Finally, candidate regions (neighborhoods of the candidate points) of the candidate points of each component are detected and after analyzing these candidate regions, components are grouped to get individual text lines.

Algorithms↗

PubMed2006

Documenting the cognitive status of hip fracture patients using the Short Portable Mental Status Questionnaire.

AIMS AND OBJECTIVES: The aim of this study was to describe how nurses document their subjective assessment of the patients' cognitive status in the patients' records and to compare this documentation with an assessment made using a validated evaluation instrument in older patients with a hip fracture. BACKGROUND: There are indications that older people with a hip fracture and impaired cognitive ability do not receive optimal care and that they suffer from a disproportionately high number of complications. Preventing and rapidly detecting confusion is probably an effective strategy for improving care for these patients. To be able to prevent care-related complications and plan for future nursing and medical care, it is necessary to identify patients with impaired cognitive ability. DESIGN: Clinical trial including 362 patients. METHODS: The patients' cognitive function was assessed by a research nurse using a validated instrument, the Short Portable Mental Status Questionnaire, and an independent subjective assessment was made by a ward nurse. The agreement between these assessments was analysed. RESULTS: An assessment of cognitive function by the ward nurse was lacking in 12% of the patients. The assessment made by the nurses did not correspond to the level of orientation according to Short Portable Mental Status Questionnaire in 24% of the patients. In the vast of majority of these cases, the patients were documented as being cognitively alert although they were cognitively impaired according to the Short Portable Mental Status Questionnaire. Among the patients who were cognitively oriented according to the Short Portable Mental Status Questionnaire, the nurses' assessment identified 97% as oriented, but among the patients with impaired cognitive ability according to the Short Portable Mental Status Questionnaire, only 58% were identified as being cognitively impaired by the ward nurses. CONCLUSIONS: An assessment of cognitive function is still lacking in nursing records for a substantial number of older people with a hip fracture and cognitive dysfunction is frequently underdiagnosed in routine health care. RELEVANCE TO CLINICAL PRACTICE: Patient care could be improved if the patients' cognitive function was assessed regularly and objectively by means of a validated evaluation instrument.

Activities of Daily Living↗

PubMed2006

In search of details of patient teaching in nursing documentation--an analysis of patient records in a medical ward in Sweden.

AIM: The aim of this study was to identify terms and expressions indicating patients' need for knowledge and understanding, as well as nurses' teaching interventions, as documented in nursing records. BACKGROUND: Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. METHODS: Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients' need for knowledge and understanding and terms and expressions indicating nurses' teaching activities were analysed. RESULTS: The results showed that patients' need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses' implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. RELEVANCE TO CLINICAL PRACTICE: Efforts must be directed towards elaborating upon the above-mentioned terms and expressions as indications of patients' need for knowledge and nurses' teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.

Adult↗

PubMed2005

Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care?

BACKGROUND: The number of intensive care units (ICU) using a clinical information system (CIS) is increasing. It is believed that replacing manual charting with an automatic documentation system allocates nurses more time for patient care. The objective of this study was to measure changes in nurses' working time utilization after the implementation of a CIS in a polyvalent ICU of a large Finnish central hospital. METHODS: An activity analysis-based comparison of the ICU nurses' working time utilization before and after the implementation of a CIS. RESULTS: After the implementation of a CIS the total time the nurses spent on documentation of nursing care increased by 3.6% (NS), 15 min per shift of 8 h per nurse. The total time they spent on patient care increased by 5.5% (P < 0.05), 21 min. Intensive care nursing activities increased by 3.7% (P < 0.05), 14 min. The length of the nurses' ICU experience had some effect on these figures. The demand for nurse labor remained constant. CONCLUSIONS: After the implementation of a CIS, an increase in the time nurses spent on documentation of care was detected, which suggests a need for further development of the system. As all the measured time changes were relatively small, any plans to reduce the ICU staff number with the aid of computers were not justified.

Clinical Laboratory Information Systems↗