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At least 793 records · Page 44Linked to original sources
PubMed1999

Documentation on trial: nine ways to protect your agency.

In today's environment, home care professionals are often overwhelmed with documentation requirements. Licensure and certification surveyors, Office of Inspector General staff, third-party payors, fraud and abuse inspectors, courtroom attorneys, and others seem to scrutinize home care documentation constantly. In short, home care documentation is always "on trial." These tips can help agencies protect themselves in this environment.

Confidentiality↗
PubMed1999

How to document patient education effectively.

While policies, procedures, and teaching sheets help establish the credibility of your patient education program to the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, they don't go far enough. To prove you really do provide effective patient education, you must document your efforts. The first step is to formulate an interdisciplinary documentation form according to Joint Commission standards. To make sure the form is used, provide adequate training for staff in all disciplines, and include documentation of patient education as part of each employee's performance appraisal.

Accreditation↗
PubMedDate not supplied

'Not for resuscitation': guidelines for decision making and documentation.

In 1991, the government's Chief Medical Officer made it clear that the responsibility for resuscitation policy lay with consultants, and that they should ensure this policy was understood by all staff caring for a patient, in particular junior medical staff. Since then, many hospitals and trusts have provided members of the multidisciplinary team with guidance on how to ensure that adequate and satisfactory communication is in place to record a patient's resuscitation status. However, as is common in the NHS, poor documentation is still evident. Guy's & St Thomas' Hospital Trust has been using a document since April 1998 which is clearly written, user friendly and does not contain ambiguous statements. With ongoing audit of this policy document we hope to reduce the incidence of inappropriate resuscitation attempts which are costly, both emotionally and financially, for all concerned.

Decision Making↗
PubMed2000

Requirements for speech recognition to support medical documentation.

Recent advances in the development of automated speech recognition (ASR) have made routine applications for medical documentation possible. To achieve this, ASR has to be optimally integrated into the specific documentation scenario. The classification presented in this paper allows the definition of specification requirements. For two different documentation scenarios the appropriate product selection has been done according to this classification. Two evaluation studies are presented, addressing the usefulness of applying automated speech recognition.

Data Collection↗
PubMed1999

Documenting the impact of hospice.

Hospice care has had an impact at many levels--on individual patients and families, on the health care industry, and on society. However, no comprehensive body of evidence has been generated that documents the impact of hospice care in terms that are meaningful to competitors, referral sources, and consumers. In part, this is because of the many challenges for evaluating hospice care. This paper describes recent efforts in the documentation of the value of hospice which have focused on outcomes measurement by individual providers rather than on large scale studies. Several groups are working to develop reliable measurement tools, to support standardized measurement in large numbers of hospices, and to collect information for benchmarking and comparison. Measurement of the impact of hospice care will set standards for other providers of end-of-life care and will document the expertise and knowledge of hospice professionals. Once established as centers of excellence in care of the dying, hospices will be well positioned for whatever delivery models may evolve for end-of-life care.

Documentation↗
PubMed2000

Trauma form documentation in major trauma.

AIMS: To examine the impact of a standardised trauma form for documentation in cases of major trauma, a prospective study was undertaken. METHODS: Records written by medical staff pertaining to the assessment and treatment of major trauma patients in the resuscitation room were scored against a panel of parameters derived from advanced trauma life support guidelines. Demographics, aetiology, trauma scores and outcome data were obtained from a trauma registry. Attitudes of medical staff involved in major trauma to the trauma form were assessed using a questionnaire. RESULTS: The trauma form was used in 53 of 69 (76.8%) consecutive cases of major trauma seen over a three month period. No significant differences existed in demographics, aetiology, trauma scores or outcome between form and formless groups. In the form group, a median of 44 of 51 (86.3%) relevant information parameters were documented versus 32 of 51 (62.7%) in the formless group, p < 0.0001. A positive approach to the trauma form was indicated by the questionnaire results. CONCLUSION: The use of a standardised form improves documentation in major trauma.

Accidents, Traffic↗
PubMed2000

[Diabetes risk factors in the Regional Railway Hospital in Lublin, described on the basis of medical documentation].

Nowadays, more and more attention is paid to the occurrence of diabetes risk factors and then to treating and preventing that disease. The objective of the study was to find out the risk factors of diabetes in a group of railwaymen hospitalized in 1997 in the Regional Railway Hospital in Lublin, on the basis of medical documentation. Medical records were analyzed, having in view diabetes risk factors such as genetic ones, overweight and addictions of the patients suffering from diabetes. All the mentioned above risk factors were obserwed in the group. The medical documentation dealing with the diabetes risk factors of the hospitalized patients was incomplete. Therefore, a conclusion was drawn, concerning the necessity of introducing into the medical documentation of diabetes patients the chart of Diet Care basic information as well as the obligation of its detailed filling in, which would allow better recognition of the diabetes risk factors and to improve the results of curing the disease.

Adolescent↗
PubMed2000

The electronic medical record: using documents for information capture.

This work concerns the management of electronic medical records. Classical systems based on databases do not satisfy end users, as the provided capture forms are never completely adapted to the patient case and to the physician's way of working. Electronic documents proved to be a better user interface paradigm, but still do not provide satisfying querying performance. Our work concerns the use of semi-structured documents as a user interface for a database-based system. The captured documents are analyzed so that information is extracted and used to fill in a database. We illustrate our proposition with the prototype we have developed and a short example.

Data Collection↗
PubMed2000

Planning and introduction of clinical documentation in an university hospital.

At the Innsbruck University Hospital the documentation planning for the new hospital information system started by designing the structure of free text documents. This paper analyzes the needs of the physicians to document and retrieve information on a patient's visits and history. Considerations for the realization of these needs are outlined. Based on our experiences the organizational constraints e.g. validation of clinical information are demonstrated and discussed.

Austria↗
PubMed2000

Comparison of manual and automated documentation of adverse events with an Anesthesia Information Management System (AIMS).

In this study, an Anesthesia Information Management System (AIMS) is used for the comparison of manually recorded adverse events with automatically detected events from anesthesiological procedures. In 1998, data from all anesthesia procedures, including the data set for quality assurance defined by the German Society of Anesthesiology and Intensive Care Medicine (DGAI), were recorded online with the documentation software NarkoData 4 (IMESO GmbH, Hüttenberg, Germany) followed by storage into a relational database (Oracle Corporation). The occurrence of manually recorded adverse events, as defined by the DGAI, is compared with automatically detected events. Automated detection was done with SQL-statements. The following adverse events were selected: hypotension, hypertension, bradycardia, tachycardia and hypovolemia. Data obtained from 16,019 electronic anesthesia records show that in 911 patients (5.7%), one of the selected adverse events was documented manually whereas in 2,996 patients (18.7%) a adverse event was detected automatically. The incidence of automatically detected events is obviously higher compared to manually recorded events. With the help of an AIMS, automatic detection proved significant deficiencies in the manual documentation of adverse events.

Anesthesia↗
PubMed2001

Implementation of Toxicall: impact on documentation.

On January 1, 1999, the Washington Poison Center implemented Toxicall; 6 mo later we measured its impact on time devoted by staff for telephone interchange, information retrieval from other than Poisindex, and documentation, and to compare it with prior studies of our conventional paper-pencil system. Previous "time and motion" studies over the past decade, using random alarm devices (Devilbiss Electronics) provided data for comparative purposes. We developed a computer-based alarm system for timing and station selection and for recording observed behaviors. Over a 6-w period, 211 calls were analyzed; the percentage of time involved for each call was compared to a 1993 study. An increased, rather than anticipated decreased, documentation effort was observed (p< 0.05), but staff participation in activities other than those listed fell dramatically suggesting increased staff efficiency. Although documentation efforts consume so much time, Toxicall provided the non-debatable benefit of eliminating illegible staff handwriting!

Computers↗
PubMed2000

Documentation of anemia management interventions. Case study of the anemic patient.

Documentation is an integral part of good anemia management. In addition to relaying vital clinical information, documentation demonstrates how nurses and other medical professionals are striving to achieve the standards of care mandated by law, their profession, third party payers, and individual health care providers. Proper documentation of anemia management practices should include a written chronological history of the rationales, plans, interventions, and evaluations initiated to achieve patient-specific Hb/Hct target levels across the spectrum of care.

Anemia↗
PubMed2000

[What we can learn on risk assessment of chemicals from the Concise International Chemical Assessment Document (CICAD) Project].

IPCS (the International Programme on Chemical Safety) has launched a new project on the Concise International Chemical Assessment Document (CICAD) as one of its major targets, which is to assess health and ecological risk from exposure to toxic chemicals in the environment through international collaboration. In this project, the author and others successfully established a framework in fulfilling ambitious aims of developing concise, but useful risk assessment documents on chemicals, while assuring credibility and efficiency in the process, and incorporating new ideas from ever developing risk assessment methodology and related sciences. This combination of usefulness in the outputs, the credibility and efficiency in the process, and the flexibility in the ideas reflecting scientific progress, shows a good example of what we should do in improving our risk assessment in this country and developing assessment documents.

Animals↗
PubMed2001

[Requirements for documentation by the physician].

Medical documentation, which is required by law, serves various purposes: for therapy, to provide information to other physicians who are or may be involved; as a record if there is any disagreement with a patient; and for invoicing purposes. Depending on which of these aspects is being addressed, the documentation is expected to satisfy different demands. With regard to liability, any information pertaining to the patient's medical condition should be recorded as soon as possible in correspondence to the principles of truth and clarity. For the health insurance companies, all treatments and services rendered must be submitted in writing. The power of proof of medical documentation is understood differently from the point of view of liability and health insurance law.

Documentation↗
PubMed2002

Assessment of the quality of medical documents issued in central police stations in Madrid, Spain: the doctor's role in the prevention of ill-treatment.

Doctors sometimes assess allegations of ill-treatment. Reports from such examinations may be used if the practice of the police is to be appraised: they should therefore be relevant and exhaustive. We assessed, retrospectively, the quality of 318 medical documents concerning 100 persons held in central police stations in Madrid, Spain, from 1991 to 1994. In 71 documents concerning 44 persons the doctors quoted the detainee as alleging ill-treatment. Most of the documents appeared to lack significant information on history of ill-treatment and description of the clinical examination. Of 34 conclusions, ten were unacceptable and the premises were insufficient in 16. These observations point to weaknesses and needs for improvements in the fulfillment of the role of doctors as safeguards of the rights of detainees. Medical examinations should be conducted outside the control of police officers, by a neutral doctor using a check-list/protocol. The quality of the report should fulfill international standards.

Adult↗
PubMedDate not supplied

Documentation of model-based practice: one hospital's experience.

Nursing conceptual models have been useful tools to guide clinical practice. They help define nursing as well as provide a consistent and efficient means of communication within the profession. One of the greatest challenges in implementing the use of a nursing conceptual model is adjusting current documentation to reflect the model appropriately. When the Neuman Systems Model was adopted as the nursing conceptual model to be implemented at our institution, we faced this challenge. Throughout the process of implementation, various documents were revised or created, including the Pediatric Admission Database and the Neuman Process Summary. In addition, registered nurses were educated on how to improve documentation in order to better use the concepts of the model.

Child↗
PubMed2002

Successful interdisciplinary documentation through nursing interventions classification.

Automated documentation systems enable health care professionals to develop dynamic, interdisciplinary care plans. Use of a standardized nomenclature provides a common framework and language for the communication of the plan, and also can support data collection to determine best clinical practices. A comprehensive patient care record will link the interdisciplinary care plan to clinical charting and the documentation of outcomes. This article reviews efforts to improve interdisciplinary communication by computerizing the documentation system, using the Nursing Interventions Classification (NIC).

Benchmarking↗
PubMed2002

Brain death documentation: analysis and issues.

OBJECTIVE: Specific guidelines for documenting the complete loss of brain function, for the declaration of brain death, have been established for 3 decades. This study assessed the quality and completeness of brain death notes and the effects of delays between notes on organ procurement. METHODS: A retrospective review of brain death declarations at a major medical center was performed. Fifty-eight cases, with a total of 121 brain death notes, were identified in a 12-month period. Notes were assessed for clinical and confirmatory tests of brain and brainstem function. Adverse physiological events that occurred in the time intervals between notes were also identified. RESULTS: The clinical tests most likely to be documented were tests of pupillary (86%) and gag (78%) reflexes. Corneal reflexes were tested in only 57% of cases, and motor responses were noted in only 66%. Documentation by the neurosurgery department was generally more complete. The delays between brain death declarations were highly variable but did not result in any loss of donor organs because of hemodynamic derangements. CONCLUSION: To meet the needs of organ recipients and donor families and to comply with hospital, legal, and legislative mandates, hospitals may need to increase quality assurance activities with respect to declarations of brain death. Increased physician education should improve awareness of uniform brain death declaration guidelines.

Adolescent↗