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At least 775 records · Page 43Linked to original sources
PubMed1999

Telemedical record documentation: a preliminary survey.

Telemedical records are the weak link in telemedicine. With a number of medicolegal and reimbursement issues still unresolved, telemedical record documentation will be a critical piece of the puzzle when the patient's original legal medical record must be produced. A questionnaire was distributed to active telemedicine programmes in the USA to determine how interactive teleconsultations were being documented. Forty programmes completed the questionnaire. The responses indicated a lack of consistency and a need for documentation guidelines for telemedical records.

Documentation↗
PubMedDate not supplied

Acute surgical wound care. 4: The importance of documentation.

This article, the last in a series of four, discusses the importance of documenting wound care. Studies have shown that nurses do not document wound care as often, or as accurately, as they should in order to comply with the UKCC's (1998) Guidelines for Records and Record Keeping. Although some wound assessment charts have been published and are in use, there is still concern about the validity or reliability of some of these charts. Studies show that further research is necessary in order to validate the charts that are currently in use. An increase in litigation has placed more emphasis on accurate record keeping which shows, in detail, the wound care that is given to each patient. Patients also want to be more informed about their treatment, and this can be done through the use of clinical pathways or multidisciplinary documents. This article also discusses the factors that have to be considered when putting a wound care chart together and gives some examples of existing charts.

Acute Disease↗
PubMedDate not supplied

Exploring the legal status of healthcare documentation in the UK.

This article considers the legal status of documentation and the point at which records become legal documents. It outlines the powers of the courts that require any documentation or other records to be produced if relevant to an issue arising in a dispute. It also discusses hearsay evidence and the fact that usually evidence on records needs to be corroborated.

Confidentiality↗
PubMed2005

[A documentation form for the consultation-liaison service: development of the CL-BaDo].

OBJECTIVES: In consultation liaison (CL) psychiatry and psychosomatics a multicenter documentation form for the assessment of clinical characteristics of patients and CL service delivery is urgently needed for health care planning and future mental health research. METHODS: In several steps a joint working party of the psychosomatic and psycho-therapeutic societies in Germany (German College for Psychosomatic Medicine, German Society of Psychosomatic Medicine and Psychotherapy, General Medical Society for Psychotherapy) developed a documentation form for C-L service (CL-BaDo). The goals and quality criteria of the patient registration form are defined in an extended consensus process of C-L experts. A pool of formerly 60 items was reduced to 36 items collecting data concerning sociodemographic characteristics, referral information, anamneses, actual psychiatric and somatic status and diagnoses, C-L interventions and treatment recommendations. To enable comparisons, the formulation of items are adapted to existing inpatient and outpatient documentation forms (Psy-BaDo,EuroQA-CL). A special manual guides the coding of the CL-BaDo. RESULTS: 16 CL services in Germany and Austria participated in the testing and pilot study of six months demonstrating the comprehensibility and fast completion of CL-BaDo and consultants' high acceptance of the form. A time-saving and user-friendly electronic version for data entry and data analyses was developed using hand-held technology. CONCLUSION: The data of the CL-BaDo can be used for 1) quality management and communication purposes with referring departments and 2) for multicenter collaborative studies, mental health care management and care planning.

Comorbidity↗
PubMed2006

Fourier transform hyperspectral visible imaging and the nondestructive analysis of potentially fraudulent documents.

The work presented in this paper details the design and performance characteristics of a new hyperspectral visible imaging technique. Rather than using optical filters or a dispersing element, this design implements Fourier transform spectroscopy to achieve spectral discrimination. One potentially powerful application of this new technology is the non-destructive analysis and authentication of written and printed documents. Document samples were prepared using red, blue, and black inks. The samples were later altered using a different ink of the same color. While the alterations are undetectable to the naked eye, the alterations involving the blue and black inks were easily detected when the spectrally resolved images were viewed. Analysis of the sample using the red inks was unsuccessful. A 2004 series 20 US dollars bill was imaged to demonstrate the application to document authentication. The results argue that counterfeit detection and quality control during printing are plausible applications of Fourier transform hyperspectral visible imaging. All of the images were subjected to fuzzy c-means cluster analysis in an effort to objectively analyze and automate image analysis. Our results show that cluster analysis can distinguish image features that have remarkably similar visible transmission spectra.

Documentation↗
PubMed2007

Documentation of pharmacists' interventions in an emergency department and associated cost avoidance.

PURPOSE: An analysis was conducted of pharmacist interventions and resuscitation experiences, including pharmacist participation in a hospital emergency department (ED), and the potential cost avoidance associated with the interventions made by the pharmacists. METHODS: All pharmacists working in the ED prospectively documented the pharmacist interventions that were accepted by physicians and nursing staff and entered into a spreadsheet on a weekly basis, between September 1, 2003, and December 31, 2003. Intervention categories included the provision of drug information; recommendations for dosage adjustment, formulary interchange, initiation of medications, alternative drug therapy, discontinuation of drug therapy, changes in medication therapy due to allergy notification, drug therapy duplication prevention, or changes in the route of drug administration; questions from nursing staff; order clarifications; drug compatibility issues; patient information; toxicology; and drug interaction identification. Intervention data were analyzed and the likelihood of harm was scored; interventions were classified and analyzed by calculating average cost, probability of harm, and potential cost avoidance. RESULTS: During the study, 2150 pharmacist interventions were documented. Pharmacists participated in the care of 1042 patients triaged to the resuscitation area of the ED. Cost avoidance during the study was determined to be 1,029,776 dollars. CONCLUSION: The most commonly documented interventions made by pharmacists involved in the care of patients visiting the ED included provision of drug information, dosage adjustment recommendations, responses to questions from nursing staff, formulary interchanges, and suggestions regarding initiation of drug therapy. The potential cost avoidance attributable to the pharmacist interventions during the study period was over 1 million dollars.

Cost Control↗
PubMed2005

[Networking of documentation practices in health education committees].

A national network of health education information officers was established at the end of 2001. The aim and objective of this group is "to contribute to the development of a solid, coherent documentation service delivery for the health education field in France." The professionals decided to commence by undertaking an assessment of the documentation activities in both the regional and departmental health education committees in order to establish sub-working groups which would collaborate to better achieve this goal. The survey's results have shown that there are existing skills and competencies available within the different committees in spite of current gaps between the various regions and department in terms of their levels of qualifications, resources and information activities and practices. It is for this reason that the national network of health education information officers designed and implemented the smaller working groups in order to gradually enable them to solidify and strengthen the network to ensure that they have the capacity to meet the stated objectives. This approach could constitute the basis for a national health education documentation network as described and called for by the law delineating the missions of the French Institute for Prevention and Health Education (Inpes).

Community Networks↗
PubMed1994

Factitious HIV infection: the importance of documenting infection.

OBJECTIVE: To examine possible causes for factitious human immunodeficiency virus (HIV) infection among patients in an HIV clinic. DESIGN: Retrospective chart review, a case-control study, and a survey of local hospital practices for documenting HIV infection. SETTING: Clinical acquired immunodeficiency syndrome (AIDS) program at a municipal hospital. RESULTS: Seven patients with self-reported, undocumented HIV infection were identified as HIV seronegative after a mean of 9.2 months of care in our clinical AIDS program. The median CD4 count for these patients was 740 cells/mm3; 6 patients had a history of illicit narcotic use and clinical symptoms consistent with HIV disease. Compared with 70 randomly selected controls from HIV clinics, patients with factitious HIV infection had higher CD4 counts (difference, 519 cells/mm3; P < 0.001) and were more likely to have an HIV-infected sexual partner (odds ratio, 15.0; P = 0.005) and a history of a suicide attempt (odds ratio, 9.8; P = 0.02). Known cases of alleged HIV infection have occurred at 8 of the 10 other local hospitals surveyed. However, only 1 of the 10 hospitals routinely documented HIV infection in patients before initiating care. CONCLUSIONS: Limitations of the current serologic tests for HIV, the use of anonymous HIV testing, and recent reports of factitious HIV disease or immune deficiency syndromes that may mimic AIDS underscore the need for clear documentation of HIV infection before medical care is started.

Adult↗
PubMed1992

Do we have to document pharmacotherapeutic interventions?

We have suggested that some pharmacotherapists may resist documentation because they view it as administrative intrusion rather than an essential component of continuity of care. In the final analysis, it is also a matter of the pharmacotherapist's belief. Pharmacists must understand what it is that they contribute, and must believe that it is both valuable and unique. It is not just an information management function--they are making patient-specific decisions and must be willing to be held accountable for their outcome. The pharmacy manager must also believe that such a responsible decision-making role represents that preferred future for the profession. Unfortunately, because many pharmacy managers have never truly functioned in such a role, developing such a belief system is difficult at best. The hospital administrator must also be made to believe that the contribution of the pharmacist to patient care not only extends beyond materials management but represents an entirely separate professional function. This will not occur simply through documentation of interventions. Yes, we believe that it is necessary to document pharmacotherapeutic interventions, however, not for the reasons that it is most frequently demanded.

Decision Making↗
PubMed1996

Validating a clinical workload measurement instrument for documenting pharmaceutical care.

The purpose of this study was to develop and validate a workload documentation instrument to manually record clinically oriented pharmaceutical care activities. Previous research documents clinical workload by pharmacists; however, the tools employed have not been tested for validity. Reported information is difficult to interpret since individuals are unlikely to categorize activities in a consistent manner. PharmaTrend was used as a template for defining activity and problem categories that corresponded to various clinical activities performed by our clinical, faculty, and staff pharmacists. Because the institution was not completely computerized, the actual documentation tool was portable and manual. Testing of the original instrument was accomplished using a survey consisting of written scenarios. Two phases of testing were required to achieve an overall 80 percent accuracy rate. At least 60 percent of available pharmacists participated in both phases and completed 90 percent or more of the surveys. The investigators concluded that an instrument to record clinically oriented pharmaceutical care activities had been developed, tested, and validated.

Documentation↗
PubMed1998

Plan of care ensures proper documentation.

Via Christi Regional Medical Center in Wichita, KS, uses a plan of care form to document patient care from pre-op to post-discharge, except for the intraoperative phase. The comprehensive form ensures good note-taking, even from traditionally poor documenters. A clinical pathway begins on page three of the form and covers tests, treatment monitoring, prescriptions, activity, discharge planning, nutrition, education, and consults for patients in partial day surgery, pre-op and post-op, holding area surgery, and the post anesthesia care unit. Potential problems areas for patients are documented in the following areas: comfort, skin integrity, communication, psychosocial, safety, mobility, physiological, and spiritual.

Critical Pathways↗
PubMed1988

Quality documentation. Quality care.

Providing home care services is becoming a greater challenge as the resources of professional staffing, time, and money become more scarce. However, simultaneously, the need for quality services is increasing as the numbers and needs of people requiring these services increase. Since home care services are essentially "invisible" because they are rendered behind the closed doors of the patient's house, assuring quality becomes dependent on the documentation. This article has presented a framework for organizing care and the documentation of care which provides both a comprehensive assessment and systematic process for uniformly managing that assessment. Us of this framework provides one way to define home health services for both home health personnel and others. Having such a definition focuses everyone's efforts and moves the industry toward quality care and quality documentation.

Documentation↗
PubMed1988

Construction documents.

Contractors base their bids on construction documents and use them as their daily "nuts and bolts" guide in constructing the building. They are the owner's legal instrument to insure that the building they want is constructed as they intended. This article defines and examines the vital significance of construction documents. Of particular interest is the discussion of owner and architect responsibilities during the construction documents (CD) phase, contractual agreements on these responsibilities, and how to minimize potential problems.

Architecture↗
PubMed1989

Computerized documentation of clinical pharmacist interventions.

An intervention documentation system can be an extremely effective patient care and management tool. The system currently in effect at UCSD Medical Center owed its success primarily to computerization. Using a computerized documentation system, the clinical pharmacists documented their activities in a quick and simple manner without ever leaving the patient care areas. In this way, the clinical pharmacists could concentrate their efforts on positively affecting therapeutic patient care outcomes with minimum disruption. On the management side, the Department of Pharmacy now has a very powerful method to demonstrate the activities of the clinical pharmacist to hospital administration. The future of this type of a program is to effectively demonstrate positive patient care outcomes as a result of the activities of a comprehensive clinical pharmacy program.

California↗
PubMed1999

[Documentation. A prerequisite for quality management].

For the judgment of the quality of medical services and for the progress of clinical medicine the comparison of data and informations of the diagnostic and therapeutic process is demanded. Therefore a systematic and concrete system of documentation should be implemented in every clinic, which consists of standard nomenclature, classification, instruments of outcome measure and documentation standards. There are a group of problems and barriers which stand in the way of this goal. It is useful to build a minimum basis data set which includes core criteria of clinical documentation in orthopedic surgery and include this in an information system so that all of these parts are considered and that a central and comparable data pool is offered for patient care, quality management and research.

Documentation↗
PubMed1999

Avoid the paper chase. Real-time, wireless patient documentation helps therapists save both time and money.

UNLABELLED: Good Shepherd Medical Center's physical therapy clinic, Longview, Texas. PROBLEM: Streamlining documentation processes in hard-to-reach areas of an off-site facility. SOLUTION: Implementing handheld, point-of-care devices for real-time documentation. RESULTS: Reduction in the time and effort physical therapists spend on "back office" documentation procedures. KEYS TO SUCCESS. "With the wireless link the staff doesn't have to concern itself with technical terms, uploads and network logons. They just enter their information by answering pre-programmed prompts. The information flows over to the host computer in real time."

Documentation↗
PubMed1998

Self-documenting structured reports using open information standards.

Structured reporting systems use standardized data elements and predetermined data-entry formats to record observations. This article describes a system for structured data entry and reporting that generates reports encoded in the Standard Generalized Markup Language (SGML), an open, internationally accepted standard for document interchange. The structured report is self-documenting: it includes a definition of its allowable data field and values encoded as a report-specific SGML document type definition (DTD). By linking its reporting concepts with those of external vocabularies such as the UMLS Metathesaurus, this system can create open, universally comprehensible structured reports.

Data Display↗
PubMed1999

[Documentation in law and general practice].

The law requires medical personnel, both physicians and non-physicians, engaged in care of patients, to document the adequate care of patients. The documentation may not become an end in itself with the concomitant extra labour involved; rather, its value lies in its being one element in the quality control of treatment and care. Feared legal sanctions in the form of reversal of the onus of proof, and equally so legal claims as a consequence of recently introduced legislation in the form of the Medicinal Products Law concerning liability of endangerment, can be avoided through suitable documentation applying labour-saving standards.

Diabetic Foot↗