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PubMed2005

Modes of rationality in nursing documentation: biology, biography and the 'voice of nursing'.

This article is based on a discourse analysis of the complete nursing records of 45 patients, and concerns the modes of rationality that mediated text-based accounts relating to patient care that nurses recorded. The analysis draws on the work of the critical theorist, Jurgen Habermas, who conceptualised rationality in the context of modernity according to two types: purposive rationality based on an instrumental logic, and value rationality based on ethical considerations and moral reasoning. Our analysis revealed that purposive rationality dominated the content of nursing documentation, as evidenced by a particularly bio-centric and modernist construction of the workings of the body within the texts. There was little reference in the documentation to central themes of contemporary nursing discourses, such as notions of partnership, autonomy, and self-determination, which are associated with value rationality. Drawing on Habermas, we argue that this nursing documentation depicted the colonisation of the sociocultural lifeworld by the bio-technocratic system. Where nurses recorded disagreements that patients had with medical regimes, the central struggle inherent in the project of modernity became transparent--the tension between the rational and instrumental control of people through scientific regulation and the autonomy of the subject. The article concludes by problematising communicative action within the context of nursing practice.

Aged↗
PubMed2006

Brief report: Failure of an electronic medical record tool to improve pain assessment documentation.

OBJECTIVE: To comply with pain management standards, Bellevue Hospital in New York City implemented a mandatory computerized pain assessment screen (PAS) in its electronic medical record (EMR) system for every outpatient encounter. We assessed provider acceptance of the instrument and examined whether the intervention led to increased documentation of pain-related diagnoses or inquiries. DESIGN: Cross-sectional survey; a pre- and posthistorically controlled observational study. SUBJECTS AND MEASUREMENTS: The utility of the computerized tool to medicine housestaff and attendings was assessed by an anonymous survey. We conducted an electronic chart review comparing all adult primary care patient encounters over a 2-day period 6 months prior to implementation of the PAS and on 2 days 6 months after its implementation. RESULTS: Forty-seven percent of survey respondents felt that the computerized assessment tool was "somewhat difficult" or "very difficult" to use. The majority of respondents (79%) felt the tool did not change their pain assessment practice. Of 265 preintervention patients and 364 postintervention patients seen in the clinic, 42% and 37% had pain-related diagnoses, respectively (P=.29). Pain inquiry by the physician was noted for 49% of preintervention patients and 44% of the postintervention patients (P=.26). In 55% of postintervention encounters, there was discordance between the pain documentation using the PAS tool and the free text section of the medical note. CONCLUSION: A mandatory computerized pain assessment tool did not lead to an increase in pain-related diagnoses and may have hindered the documentation of pain assessment because of the perceived burden of using the application.

Adult↗
PubMed2000

A continuous quality improvement approach to IL-372 documentation compliance in an academic emergency department, and its impact on dictation costs, billing practices, and average patient length of stay.

OBJECTIVE: To determine whether continuous quality improvement (CQI) methodology could improve and maintain IL-372 documentation compliance in an academic emergency department (ED). The impact on transcription costs, billing practices, and average patient length of stay was also analyzed. METHODS: Baseline IL-372 compliance data were collected and shared with staff during a multidisciplinary educational session. Faculty dictation became mandatory. Pocket-sized dictation templates were provided. A Documentation Improvement Committee monitored outcomes. Each month of the study period, a compliance officer reviewed approximately 100 records. The following indicators were monitored: IL-372 compliance rates, dictation rates, transcription costs, down-coding rates, percentage of billable records, and average patient length of stay. Individualized results were provided to faculty. RESULTS: During the ten-month study period, compliance rates increased from 60% to 100% (p-trend < 0.001), while dictation rates increased from 69% to 100% (p < 0.001). Rates of down-coding adjustments improved from 54% to 2% (p-trend < 0.001). The percentage of billable records increased from 65% to 100% (p-trend < 0.001). Transcription costs increased a modest 16%. The average patient length of stay remained unchanged. CONCLUSION: The application of CQI methodology, combined with the availability of dictation, resulted in sustained improvement in IL-372 compliance. This was associated with a parallel increase in dictation rates, although concurrent transcription costs increased only modestly. The percentage of billable records increased, while the number of charts requiring down-coding decreased, both beneficial outcomes. Average length of stay was not adversely impacted by this added documentation requirement.

Academic Medical Centers↗
PubMedDate not supplied

Complying with Joint Commission nursing standards: practical documentation tools.

The need for accurate and complete documentation of nursing care has grown as hospitals seek to comply with the new requirements of the Joint Commission on Accreditation of Healthcare Organizations. As of January 1991, the Joint Commission implemented standards for nursing services that include documentation of the planning and delivery of nursing care. While the new JCAHO standards do not call for a separate nursing care plan, they nevertheless involve enough changes to require modification of most currently used documentation forms. This article describes the methods used to design new forms at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix, AZ. The newly developed forms are reviewed and compared with the Joint Commission's new standards and scoring guidelines.

Arizona↗
PubMedDate not supplied

Improving the quality of medical record documentation.

Accurate and complete medical record documentation is essential in any healthcare setting. In addition to communicating vital patient care information, the medical record provides documentation of appropriate evaluation, treatment, and services. It also is used to evaluate practitioner performance, to monitor resource use, and to determine reimbursement. In this article, Carol Ann Martin describes the efforts of one hospital to revise and upgrade its medical record documentation by means of continuous quality improvement strategies.

Communication↗
PubMed2002

Tobacco related bar promotions: insights from tobacco industry documents.

OBJECTIVES: To examine the tobacco industry's use of bar promotions, including their target groups, objectives, strategies, techniques, and results. DESIGN: Over 2000 tobacco industry documents available as a result of the Master Settlement Agreement were reviewed on the internet at several key web sites using keyword searches that included "bar", "night", "pub", "party", and "club". The majority of the documents deal with the US market, with a minor emphasis on Canadian and overseas markets. RESULTS: The documents indicate that bar promotions are important for creating and maintaining brand image, and are generally targeted at a young adult audience. Several measures of the success of these promotions are used, including number of individuals exposed to the promotion, number of promotional items given away, and increased sales of a particular brand during and after the promotion. CONCLUSION: Bar promotions position cigarettes as being part of a glamorous lifestyle that includes attendance at nightclubs and bars, and appear to be highly successful in increasing sales of particular brands.

Adolescent↗
PubMed2006

Brand differences of free-base nicotine delivery in cigarette smoke: the view of the tobacco industry documents.

The recent availability of internal tobacco industry documents provides significant insight into industry knowledge and manipulation of tobacco smoke delivery. One critical area of research is the role of smoke chemistry in determining the absorption and effects of smoke constituents, especially harm producing or pharmacologically active compounds. Independent scientific research has suggested that the nicotine dosing characteristics, hence the addiction potential of cigarettes, may be determined in part by the amount of free-base nicotine in cigarette smoke and its effects on the location, route, and speed of absorption in the body and on the sensory perception effects of the inhaled smoke. Tobacco industry documents describe the use of a number of methods internally for measuring free-base nicotine delivery. These include the common use of cigarette "smoke pH" as a means to estimate the fraction of free-base nicotine in the particulate matter (PM) in cigarette smoke, as well as efforts to measure free-base nicotine directly. Although these methods do not provide accurate absolute measures of free-base nicotine in smoke, consistencies observed in the findings across the various manufacturers indicate: (1) real relative differences in the acid/base chemistry of the smoke from different brands of cigarettes; (2) a connection between differences in free-base levels and brand-dependent differences in sensory perception and smoke "impact"; and (3) levels of free-base nicotine that are greater than have typically been publicly discussed by the industry. Furthermore, the results of these methods are generally consistent with those of a recent study from the Centers for Disease Control and Prevention which directly measured the free-base fraction of nicotine across a range of cigarette types. Consideration of the likely fundamental importance of free-base nicotine levels in cigarette smoke, together with the efforts discussed in the tobacco industry documents to measure such levels, indicates that the public health community would benefit from additional research to assess directly the delivery of free-base nicotine in cigarette smoke across brands. This may be especially useful for those products ("light", "ultralight", "reduced carcinogen", etc) that have been promoted, either explicitly or implicitly, as "harm reducing".

Documentation↗
PubMed2003

Identification of biological relationships from text documents using efficient computational methods.

The biological literature databases continue to grow rapidly with vital information that is important for conducting sound biomedical research and development. The current practices of manually searching for information and extracting pertinent knowledge are tedious, time-consuming tasks even for motivated biological researchers. Accurate and computationally efficient approaches in discovering relationships between biological objects from text documents are important for biologists to develop biological models. The term "object" refers to any biological entity such as a protein, gene, cell cycle, etc. and relationship refers to any dynamic action one object has on another, e.g. protein inhibiting another protein or one object belonging to another object such as, the cells composing an organ. This paper presents a novel approach to extract relationships between multiple biological objects that are present in a text document. The approach involves object identification, reference resolution, ontology and synonym discovery, and extracting object-object relationships. Hidden Markov Models (HMMs), dictionaries, and N-Gram models are used to set the framework to tackle the complex task of extracting object-object relationships. Experiments were carried out using a corpus of one thousand Medline abstracts. Intermediate results were obtained for the object identification process, synonym discovery, and finally the relationship extraction. For the thousand abstracts, 53 relationships were extracted of which 43 were correct, giving a specificity of 81 percent. These results are promising for multi-object identification and relationship finding from biological documents.

Algorithms↗
PubMed2003

Documentation of asthma severity in pediatric outpatient clinics.

National asthma guidelines recommend assessment and documentation of asthma severity at each clinic visit. A cross-sectional medical record review was conducted, which found that only 34% of records had any documentation of severity in the previous 2 years. However, severity documentation is associated with other indicators of quality care such as receipt of an action plan, spacer device, peak flow meter, asthma education, and influenza vaccination. These results suggest that use of a system for classifying asthma severity compels the physician to consider the long-term management of asthma, rather than just acute treatment of the disease. Interventions to improve physician practice should continue to emphasize severity assessment.

Age Factors↗
PubMed2005

The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data.

BACKGROUND: The International Knee Documentation Committee Subjective Knee Evaluation Form may be used to measure symptoms, function, and sports activity for people with a variety of knee disorders, including ligamentous and meniscal injuries, osteoarthritis, and patellofemoral dysfunction. To date, normative data have not been established for this valid, reliable, and responsive outcomes instrument. PURPOSE: To provide clinicians and researchers with normative data to facilitate the interpretation of results on the International Knee Documentation Committee Subjective Knee Evaluation Form. STUDY DESIGN: Cross-sectional survey. METHODS: The Subjective Knee Evaluation Form was mailed to 600 people in each of 8 age/gender categories (18-24 years, 25-34 years, 35-50 years, and 51-65 years for both male subjects and female subjects). Participants were drawn from a panel of 550 000 households (1 300 000 subjects) representative of noninstitutionalized persons in the United States and were matched to data from the United States Census Bureau on geographical region, market size, income, and household size. RESULTS: Complete data were available for 5246 knees. Twenty-eight percent of respondents reported an injury, weakness, or other problem with one or both knees. Normative data were determined for respondents as a whole and for the subset of respondents with no history of knee problems. Mean scores were determined for men aged 18 to 24 years (89 +/- 18), 25 to 34 years (89 +/- 16), 35 to 50 years (85 +/- 19), and 51 to 55 years (77 +/- 23); mean scores were also determined for women aged 18 to 24 years (86 +/- 19), 25 to 34 years (86 +/- 19), 35 to 50 years (80 +/- 23), and 51 to 65 years (71 +/- 26). Scores were higher for the subset of respondents with no history of current or prior knee problems. CONCLUSION: Scores on the International Knee Documentation Committee Subjective Knee Evaluation Form vary by age, gender, and history of knee problems. The normative data collected in this article will allow clinicians to interpret how patients with knee injuries are functioning relative to their age- and gender-matched peers and will enable researchers to determine the clinical outcomes of treatment.

Adolescent↗
PubMed2004

A theoretical approach to documentation of care.

The purpose of this column is to present a theoretical background for understanding nursing care documentation. The theory used was Eriksson's theory of health and suffering. An adaptation of Gadamer's hermenuetic method was used to apply the theory to a way of thinking about clinical practice. The hermeneutic dialogue took place between Eriksson's caring science texts and clinical nursing practice. The dialogue shows that relating different dimensions of the patient's health and suffering to the dimensions of care seems to provide the necessary prerequisites for the development of a theoretical background for the documentation of care. It also allows the patient's views and experiences to be revealed in the documents related to nursing care.

Attitude to Health↗
PubMed1989

Using and documenting nursing diagnosis in an ambulatory setting.

Documentation and the use of nursing diagnosis have proved to be important in increasing the efficiency of communication and the clarification of nursing services provided. This has led to better utilization of nursing resources. The increased emphasis on ambulatory care has shifted our focus to nurses' roles in clinic and day hospital settings. How do nurses document the care they provide in an ambulatory setting? Can nursing diagnosis be used as effectively in the outpatient department as it has been in the acute or chronic inpatient hospital setting? This article describes how one agency developed a unique documentation tool for ambulatory care which allows for and encourages the use of nursing diagnosis by staff nurses, IV nurses and nurses in expanded roles, and facilitates communication among all nursing personnel.

Ambulatory Care↗
PubMedDate not supplied

Cardiopulmonary resuscitation documentation: a survey of 135 medical centers.

The pharmacist is an active member of the cardiopulmonary resuscitation (CPR) team in many hospitals, dispensing medications, maintaining records, providing drug information, calculating doses, and mixing intravenous fluids. We surveyed 135 emergency department nursing directors across the country to assess the methods of and persons responsible for documentation during CPR. Ninety-five (70 percent) completed surveys were returned, showing that documentations was usually done by a nurse (81 percent), by a nurse and pharmacist (9 percent), by a pharmacist (7 percent), or by others (ward clerks, paramedics, or physicians) (3 percent). CPR flowsheets (83 percent), nurses' notes (7 percent), or other methods (10 percent) including notes on paper towels and blackboards are used to record such information in the emergency department. Most respondents were fairly confident (49 percent) or very confident (48 percent) that they could recreate the resuscitative sequence from the information recorded; 2 percent did not have confidence in the reproducibility of the data. Respondents felt that cardiac rhythms (83 percent), drugs and dosages administered (34 percent), and temporal sequence of events (33 percent) could be more accurately recorded during CPR. A majority of respondents (57 percent) felt that an automated recording system would be useful. We conclude that there appears to be considerable variability in the method of documentation of events during CPR in emergency departments throughout the country. Future efforts in emergency care should include the involvement of pharmacists in the development and implementation of a uniform database for use by field and hospital personnel during CPR.

Data Collection↗
PubMed2005

Incomplete event documentation in medical records of lung transplant recipients.

CONTEXT: The medical record is frequently used in clinical studies as a source of information on illness events experienced by patients; however, it may be incomplete. OBJECTIVE: To estimate the extent of incompletely documented acute bronchopulmonary events in a transplant clinic medical record at a single university medical center, using home monitoring data. DESIGN, SETTING, AND SUBJECTS: Trends in daily home monitoring data were compared to contemporaneous medical record documentation at 150 different times in 30 lung transplant recipients over 45 subject-years. OUTCOME MEASURE: Proportion of acute bronchopulmonary illness events documented in clinic medical record. RESULTS: By using home monitoring data in a new way, we found that 40% of events actually suffered by lung recipients could not be ascertained to have occurred from the clinic medical record alone. All missed encounters occurred away from the transplant clinic, and involved hospitalizations and telephone prescriptions. CONCLUSIONS: Using the clinic medical record alone to identify acute bronchopulmonary events in lung transplant recipients may result in missing 40% of events. This has important ramifications for studies relying on the medical record for acute event ascertainment in lung transplantation and possibly other chronic diseases.

Academic Medical Centers↗
PubMed2005

How and why community hospital clinicians document a positive screen for intimate partner violence: a cross-sectional study.

BACKGROUND: This two-part study examines primary care clinicians' chart documentation and attitudes when confronted by a positive waiting room screen for intimate partner violence (IPV). METHODS: Patients at community hospital-affiliated health centers completed a screening questionnaire in waiting rooms that primary care providers (PCPs) were subsequently given at the time of the visit. We first reviewed the medical records of patients who screened positive for IPV, evaluating the presence and quality of documentation. Next we administered a survey to PCPs that measured their knowledge, attitudes and practice regarding IPV. RESULTS: Seventy-two percent of charts contained some documentation of IPV, however only 10% contained both a referral and safety plan. PCPs were more likely to refer patients (p < .05) who screened positively for mood or anxiety disorders, disclosed that they feared for their safety or were economically disadvantaged. Those that feared for their safety or endorsed mood or anxiety disorders were more likely to have notation of a safety plan in their records. When surveyed, 81.6% of clinicians strongly agreed that it is their role to inquire about IPV, but only 68% expressed confidence in their ability to manage it. In contrast, 93% expressed confidence in managing depression. Sixty-seven percent identified time constraints as a barrier to care. Predictors of PCP confidence in treating patients who have experienced IPV (p < .05) included hours of recent training and clinical experience with IPV. CONCLUSION: Mandatory waiting room screening for IPV does not result in high levels of referral or safety planning by PCPs. Despite the implementation of a screening process, clinicians lack confidence and time to address IPV in their patient populations suggesting that alternative methods of training and supporting PCPs need to be developed.

Documentation↗
PubMed2006

Hughlings Jackson's clinical research: evidence from contemporary documents.

Because Hughlings Jackson directed that his personal documents be destroyed upon his death, none of his own clinical records are known. However, we have discovered several pages of notes in the Royal London Hospital Archive written in 1893 by Jackson to his House Physician at Queen Square concerning his proposals for investigation of a patient with external ophthalmoplegia. We have linked this document to JC, a patient described by Jackson in Neurological Fragments, in papers published in the Lancet between 1895 and 1909. We have followed Jackson's analysis of JC through the clinical records at the London Hospital and at Queen Square. These documents illuminate the clinical and academic background to Jackson's neurological practice in late nineteenth-century London.

Biomedical Research↗
PubMed1998

The Health Care Financing Administration's new examination documentation criteria: minimum auditing standards for the neurologic examination to be used by Medicare and other payors. Report from the American Academy of Neurology Medical Economics and Management Subcommittee.

Medicare recently announced the adoption of minimum documentation criteria for the neurologic examination. These criteria are added to existing standards for the history and medical decision-making. These criteria will be used in compliance audits by Medicare and other payors. Given the current federal initiative to eliminate fraud in the Medicare program, all neurologists need to comply with these standards. These criteria are for documentation only. Neurologic standards of care require a more complex and diverse examination pertinent to the problem(s) under consideration. Further guidance as to the content of a neurologic evaluation is outlined in the article "Practice guidelines: Neurologic evaluation" (Neurology 1990; 40: 871). The level of history and examination required for specific services is defined in the American Medical Association current procedural terminology book. Documentation standards for examination of children are not yet defined.

Aged↗
PubMed2006

Changing medical group behaviors: increasing the rate of documentation of quality assurance events using an anesthesia information system.

In the United States, quality assurance (QA) documentation is required by numerous agencies for each anesthetic performed. The goal of this study was to determine the effect of several interventions on the voluntary completion rate of QA documentation. We hypothesized that optimizing workflow integration would increase both QA completion rates and complication capture rates and promote long-term successful changes in reporting behavior. Whereas electronic scanning of anesthetic records may automate some aspects of QA, there will continue to be a need for anesthesiologists to enter QA documentation that cannot be automated. Starting from a baseline completion rate of 48%, we instituted a series of interventions. We successively increased the completion rate to 55% (education), 68% (workflow integration), and 78% (individual feedback). Each intervention increased the completion rate from the previous intervention (P < 0.001). The increased completion rate suggests better overall data capture, because the percentage of "no complication" entries decreased. After the study period, the completion rate increased to 94%, principally because of the improved workflow integration. As implementation of anesthesia information systems increases, attention to user interface design may be a key component in the functionality and utility of these systems.

Anesthesia↗