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PubMed1993

Parental perception of the use and usefulness of a parent-held child health record.

This study surveyed 313 parents to investigate how frequently parents used a parent-held child health record, and whether they saw the record as useful. Since 1981, The Child, Adolescent and Family Health Service has distributed a Personal Health Record (PHR) to the parents of all children in South Australia. The PHR has provided each family with an ongoing record that has been consistently used for immunization, child health checks and child health screening. However, little is known about how parents view the PHR, its usefulness, and how frequently the record is used. Previous studies, generally conducted prior to, or shortly after, a parent-held child health record was introduced, have shown a poor understanding of the uses of the PHR on the part of parents and a low level of use by health professionals such as general practitioners. In contrast, the results of this study show high levels of understanding of the health record on the part of parents, and an increase in the use of the health record by general practitioners over the 10 years since the record was introduced. Although moderated by the age of the child, the sections of the PHR seen as most useful (and the most frequently used) by parents were immunization, growth charts, progress notes and health checks.

Age Factors↗

PubMed1998

Evaluation of linked cancer registry and hospital records of breast cancer.

BACKGROUND: Information on the treatment of women with breast cancer in Australia is generally available only from special surveys. Analysis of routinely collected datasets may be more timely and cost effective, if the data are sufficiently accurate and complete. OBJECTIVE: To evaluate the accuracy and completeness of data on treatment in linked records of breast cancer from two routinely collected datasets. METHODS: The NSW Department of Health linked NSW Central Cancer Registry (CCR) records for 2,636 women diagnosed with breast cancer in NSW in 1992 to all hospital admission records in the NSW In-patient Statistics Collection (ISC) from January 1991 to June 1994. We queried the original paper records of subsets of women to identify missing or miscoded information and cases not notified to the CCR. We also compared the treatment data with data collected independently from the medical records of 19% of the women. RESULTS: ISC records linked to 89% of the CCR records. The CCR had identified 94.9% of women with breast cancer treated as hospital in-patients and 83% of these women had surgical treatment recorded in the ISC. The linked dataset under-estimated the percentage of women having breast-conserving therapy (-4%) and slightly over-estimated the percentage having mastectomy (+1%). We estimated that 42% of women treated surgically for breast cancer had actually had breast-conserving surgery, compared with 39% in the original dataset. There was no evident bias by age or by urban or rural residence in the under-recording of breast conservation. There was 94% agreement on the type of surgery between the linked dataset and the independent dataset.

Adult↗

PubMedDate not supplied

The accuracy of medication data in an outpatient electronic medical record.

OBJECTIVE: To measure the accuracy of medication records stored in the electronic medical record (EMR) of an outpatient geriatric center. The authors analyzed accuracy from the perspective of a clinician using the data and the perspective of a computer-based medical decision-support system (MDSS). DESIGN: Prospective cohort study. METHODS: The EMR at the geriatric center captures medication data both directly from clinicians and indirectly using encounter forms and data-entry clerks. During a scheduled office visit for medical care, the treating clinician determined whether the medication records for the patient were an accurate representation of the medications that the patient was actually taking. Using the available sources of information (the patient, the patient's vials, any caregivers, and the medical chart), the clinician determined whether the recorded data were correct, whether any data were missing, and the type and cause for each discrepancy found. RESULTS: At the geriatric center, 83% of medication records represented correctly the compound. dose, and schedule of a current medication; 91% represented correctly the compound. 0.37 current medications were missing per patient. The principal cause of errors was the patient (36.1% of errors), who misreported a medication at a previous visit or changed (stopped, started, or dose-adjusted) a medication between visits. The second most frequent cause of errors was failure to capture changes to medications made by outside clinicians, accounting for 25.9% of errors. Transcription errors were a relatively ucommon cause (8.2% of errors). When the accuracy of records from the center was analyzed from the perspective of a MDSS, 90% were correct for compound identity and 1.38 medications were missing or uncoded per patient. The cause of the additional errors of omission was a free-text "comments" field-which it is assumed would be unreadable by current MDSS applications-that was used by clinicians in 18% of records to record the identity of the medication. CONCLUSIONS: Medication records in an outpatient EMR may have significant levels of data error. Based on an analysis of correctable causes of error, the authors conclude that the most effective extension to the EMR studied would be to expand its scope to include all clinicians who can potentially change medications. Even with EMR extensions, however, ineradicable error due to patients and data entry will remain. Several implications of ineradicable error for MDSSs are discussed. The provision of a free-text "comments" field increased the accuracy of medication lists for clinician users at the expense of accuracy for a MDSS.

Aged↗

PubMed2003

Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes.

Paper-based and electronic patient records generally are used in parallel to support different tasks. Many studies comparing their quality do not report sufficiently on the methods used. Few studies refer to the patient. Instead, most regard the paper record as the gold standard. Focusing on quality criteria, the current study compared the two records patient by patient, presuming that each might hold unique advantages. For surgical patients at a nonuniversity hospital, diagnosis and procedure codes from the hospital's electronic patient record (EPR set) were compared with the paper records (PPR set). Diagnosis coding from the paper-based patient record resulted in minor qualitative advantages. The EPR documentation showed potential advantages in both quality and quantity of procedure coding. As in many previous studies, the current study relied on a single individual to extract and transform contents from the paper record to compare PPR with EPR. The exploratory study, although limited, supports previous views of the complementary nature of paper and electronic records. The lessons learned from this study are that medical professionals should be cognizant of the possible discrepancies between paper and electronic information and look toward combining information from both records whenever appropriate. The inadequate methodology (transformations done by a single individual) used in the authors' study is typical of other studies in the field. The limited generalizability and restricted reproducibility of this commonly used approach emphasize the need to improve methods for comparing paper-based with electronic versions of a patient's chart.

Diagnosis-Related Groups↗

PubMed2002

Accuracy of recorded tumor, node, and metastasis stage in a comprehensive cancer center.

PURPOSE: The benefits of recording the tumor, node, and metastasis (TNM) stages of cancer patients are well accepted, but little is known about how accurately this is performed. An audit was performed to determine the accuracy of recorded stage and to act as a baseline before the implementation of an education program. PATIENTS AND METHODS: All new patient referrals to Princess Margaret Hospital between July 1 and August 31, 1997, were reviewed. An audit panel composed of five health record technicians (HRTs) and 10 doctors was assembled. Each auditor reviewed 10% of the health record. If there was a discrepancy between the stage in the health record and the auditor stage, then the final stage was determined by the audit committee. Analysis of the agreement between the health record, the physician auditor, the HRT auditor, and the final stage was performed. RESULTS: A total of 855 patients were referred with a new diagnosis of a malignancy for which there was a TNM stage system; 833 patients (97.4%) had a stage assigned. There was agreement between the health record stage and final stage in 80% (95% confidence interval [CI], 77% to 82%) of cases for clinical stage, compared with 90% (95% CI, 87% to 92%) for pathologic stage. Of the major site groups, lung was the least accurately recorded. The most common major discrepancies were due to the recording of X when a definite category could be assigned. CONCLUSION: This audit demonstrates the importance of staging and provides impetus to develop staging guidelines and education programs.

Cancer Care Facilities↗

PubMed1987

Acceptance and use of patient-carried health records.

The ultimate goals of providing health records to patients are to improve continuity of care, to improve patient understanding of instructions, and to encourage patients to take a more active role in maintaining their health. In the current study, four types of patient-carried health records were evaluated in a hospital-based outpatient service to determine whether records would be accepted and used, to estimate the cost of the process, and to obtain patient and provider reactions. Records were provided at moderate cost and the primary determinants in record acceptance and use were physicians' support of the process, the type of record, and the employment status of the patient. A small record which could be carried in a wallet seemed suited to most patients; other more elaborate participatory records appeared to have benefits for selected patients. More extensive use of participatory records appears to require changes in the way health care would be delivered.

Attitude of Health Personnel↗

PubMed1988

A professional approach to record completion.

The steady decrease in incomplete and delinquent records has been accomplished without suspending any of the attending physicians. On occasion, hospital administration has, at our request, sent the attending physicians a warning letter alerting them that they will be reported to the Hospital Medical Board if they fail to complete their records. Typical of a teaching facility, the housestaff is primarily responsible for dictation of discharge summaries. They are suspended without pay if they fail to complete their records after being warned. Another significant effect of this program has been the timely entry of ICD-9-CM codes into the billing system within five days of discharge. Accounts outstanding due to lack of final diagnoses and/or attestation statement signatures, ranging from 5-22 days post-discharge, have been reduced to an average of only 40-50 daily. (Vanderbilt University Medical Center averages 22,000 discharges annually). This new program has placed the Medical Record Department in total control of the incomplete/delinquent records. By having less than 300 records to handle, we can provide much better service to the physicians, locate needed records quickly, and maintain an excellent working relationship with the Patient Accounting Department. Medical and hospital administration staff members now regard medical record personnel as organized and effective record managers.

Centralized Hospital Services↗

PubMed2000

A structured record to implement the national guidelines for diabetes and hypertension care.

BACKGROUND: Guidelines to improve standards of care for hypertension and diabetes were disseminated by the National Department of Health in 1996 but have generally not been implemented by health professional in local primary care. A strategy for the adoption and implementation of the Guidelines was developed in collaboration with health professionals in primary care. OBJECTIVES: The development of a structured record, with prompts for the management of diabetes and hypertension according to the Guidelines. SETTING: Three community health centres (CHCs) in the Western Cape. PARTICIPANTS: Doctors and nurses managing patients with diabetes and hypertension. METHODS: A draft of the structured record was developed at a single-pilot CHC in the Western Cape. Focus group discussions established the core requirements for a structured record. Process, result and structural indicators in line with the national Guidelines were considered for inclusion in the draft record. This draft record was then piloted at two other CHCs. Comments from semi-structured interviews and pre- and post-test evaluation questionnaires were used to compile the final instrument. RESULTS: Eleven doctors and 8 nurses participated in the development of the final instrument. Important considerations in the design were a single-page, user-friendly format, tick-boxes to reduce writing, prompts, provision for sequential recording, target setting, and compatibility with the Guidelines. The final instrument was piloted and elicited a favourable overall response. CONCLUSION: The structured record simplifies the application of the Guidelines and the systematic recording of processes of care. The effectiveness of the Guidelines will be evaluated further in a randomised control trial using the structured record.

Diabetes Mellitus↗

PubMedDate not supplied

Full implementation of a computerized nursing records system at Kochi Medical School Hospital in Japan.

A project to fully implement a novel computerized nursing records system resulted in the standardization of nursing records, reduced the administrative workload for staff, enabled medical staff to know a patient's status at any given time, and improved the quality of nursing care provided to patients. The development process of the computerized nursing records system involved three main steps: 1) the establishment of a new nursing assessment form and introduction of nursing diagnosis into routine work, 2) computerized system design and construction, and 3) the usability check of the computerized nursing records system in a clinical setting for 1 year. The successful development of the computerized nursing records system was based on the following points: 1) the assessment form for nursing diagnosis was improved and the nursing diagnosis was introduced before the computerized system was designed and constructed; 2) full, rather than partial, implementation of the computerized system occurred; 3) existing knowledge of nursing assessments and standard care planning were fully used; 4) registered data were optimally reused upon summarization and readmission to reduce the nurses' workload; and 5) portable computers were introduced to enable simple and quick recording of bedside findings. The routine use of the computerized nursing records system was started in April 2000. More comprehensive investigations during the next 2 to 3 years are necessary to determine how the contents of nursing records can be improved and how much the computerized nursing records system affects the quality of nursing.

Hospital Information Systems↗

PubMed2001

Analysis of noteworthy indicators on the anesthesia record: a prospective, multiregional study.

A national sample of anesthesia records were studied prospectively for the presence or absence of predetermined, noteworthy record indicators judged important in documenting a basic core of information describing the monitoring and care provided in a generic clinical setting. Only records involving the administration of a volatile anesthetic for the purpose of achieving general anesthesia, prepared by providers with at least 6 months of experience in anesthesia care were examined. No identifying patient, provider, or institutional data were recorded. Indicators were scored in a "present/absent" format. All data were pooled; the goal was to describe the overall phenomena in terms of frequency of compliance. A total of 4,989 anesthesia records were evaluated in terms of 13 record indicators. Those missed ranged from 0.0% (patient identification) to 28.6% (notation regarding emergence). Ten were omitted on less than 6% of the records: 3 (surgery and/or anesthesia start time, notation regarding emergence, surgical positioning noted) were omitted on more han 13.0% of the records. Given he observed inconsistencies, perhaps the anesthesia record needs redesign or the rationale behind documentation requires increased emphasis in educational and equally assurance programs.

Anesthesia↗

PubMed2006

[Should patients in general practice be offered a copy of their medical record?].

BACKGROUND: Is it useful for patients in general practice to have a copy of their medical record, and will this increase the quality of the record? What do patients and their doctors think about such a practice? MATERIAL AND METHODS: Eight general practitioners participated in a study where they should ask their patients if they wanted at copy of their medical record after the consultation. The doctors were asked about what they felt about such a practice. 181 patients participated. RESULTS: 126 patients (70%) wanted to read their medical record. Among these, 118 (94%) reported that the record covered the problem they came for, 104 (83%) that it was useful to read what the doctor had written, and 96 (76%) that this practice should be more common. The doctors answered that the records became somewhat changed and longer and were more time-consuming. Most of the doctors thought that the quality of the medical record improved and that the procedure could well be standardised. INTERPRETATION: The results indicate that many patients in general practice will find it useful to read their medical record. The study may indicate a better quality of the record when doctors are aware that the patients will have a copy.

Adult↗

PubMed1977

Occupational therapy sequential client care recording system: a comparative study.

The client care record is a key document for determining standards of care in occupational therapy. The purpose of this study was to determine the effectiveness of a client care recording system for occupational therapy that combined the theoretical framework of the Developmental Analysis, Evaluation and Intervention Schedule, and the scientific method of the Problem Oriented Medical Record. The research form of the client care record was compared to a traditional client care record in current use in an occupational therapy clinic. An interdisciplinary panel of health professionals rated both the original and proposed form of the record on the variables of completeness, organization, understandability, and usefulness. The findings show statistically significant differences between the client care record based on the combined Developmental Analysis, Evaluation and Intervention Schedule and the Problem Oriented Medical Record and the currently used record system.

Child↗

PubMed1997

The completeness and accuracy of patient record transfer between practices.

OBJECTIVES: In addition to the paper record, most general practitioners now use a parallel electronic record system on their practice computer. When a patient changes practice at present, the written records are transferred from the patient's previous practice to the next. An up to date computer generated summary or print out should also be sent. Our aim was determine the completeness and accuracy of this process of patient record transfer. DESIGN: A survey of an opportunistic sample of one hundred patient records in transit between general practices during a single week. Accuracy of information transferred was assessed by examining the records. Further analysis of discrepancies was conducted by one of the authors (FS) to assess their clinical significance. SETTING: September 1995, primary care department of Lanarkshire Health Board. RESULTS: Only 46% of practices transfer the complete record compared to the 85% of practices with computers which would have been expected to do so. Even in those which transferred a paper copy of the electronic record, a total of 51% showed discrepancies between the computer and manual format in recording of some or all of the following: diagnoses, prescribing data and the results of investigations. CONCLUSION: Practices should ensure all relevant data is transferred when a patient moves from one practice to another. The current arrangements do not ensure that this occurs.

Continuity of Patient Care↗

PubMed1994

Localizing sites of intradendritic electrophysiological recordings by confocal light microscopy.

Studies were undertaken to develop microscopic methods and imaging procedures that would permit identification of sites of intradendritic microelectrode recordings from pyramidal cells in hippocampal slice preparations. Intradendritic recordings were obtained with sharp microelectrodes filled with the dye lucifer yellow. Following a recording session a neuron was iontophoretically injected with the dye and imaged by fluorescence videomicroscopy. Images were stored on videotape for later analysis. They provided a record of the location of the microelectrode recording site. After withdrawal of the microelectrode, slices were processed histologically and imaged a second time with a Bio-Rad 600 confocal attachment on an Olympus BH-2 microscope. Confocal images provided detailed anatomical information in three dimensions. In most instances, a clear identification of the recording site was achieved by comparing video images containing the recording electrode and confocal images. Neurophysiological recordings obtained from proximal and distal apical dendrites were markedly different. Proximal dendritic recordings were similar to those obtained from pyramidal cell soma. However, distal dendrites were not electroresponsive when depolarized by intracellular current injection. The techniques described here, or variations that employ patch electrodes, could provide valuable information that should further an understanding of the properties of dendrites in the central nervous system.

Action Potentials↗

PubMed2000

Operative record using intraoperative digital data in neurosurgery.

BACKGROUND: The purpose of this study was to develop a new method for more efficient and accurate operative records using intra-operative digital data in neurosurgery, including macroscopic procedures and microscopic procedures under an operating microscope. METHODS: Macroscopic procedures were recorded using a digital camera and microscopic procedures were also recorded using a microdigital camera attached to an operating microscope. Operative records were then recorded digitally and filed in a computer using image retouch software and database base software. FINDINGS: The time necessary for editing of the digital data and completing the record was less than 30 minutes. Once these operative records are digitally filed, they are easily transferred and used as database. Using digital operative records along with digital photography, neurosurgeons can document their procedures more accurately and efficiently than by the conventional method (handwriting). INTERPRETATION: A complete digital operative record is not only accurate but also time saving. Construction of a database, data transfer and desktop publishing can be achieved using the intra-operative data, including intra-operative photographs.

Humans↗

PubMed1986

Appraisal of computerized medical histories: comparisons between computerized and conventional records.

Automated patient histories in internal medicine have been compared with written medical records by investigating the diagnostic statements that were generated for both types of records by three internists. Also the intra and interobserver variability was evaluated. In addition, the opinion of the internists about the usability of the different records was investigated. To have a fair comparison, the written record was transcribed to a computerized form and also offered to the internists. Each internist evaluated in total 72 records (from 18 patients) and altogether 529 diagnostic hypotheses were generated. The intraobserver agreement was for the written record 55%, for the automated history 46% and for the transcribed record 38%. Interobserver agreement was 23.5%, the agreement between the automated patient history and the written record was 24%, between the former and the transcribed record it was 36%.

Computer Systems↗

PubMed2005

Guidelines were developed for data collection from medical records for use in retrospective analyses.

OBJECTIVE: To construct a set of guidelines for data collection from medical records. STUDY DESIGN AND SETTING: Retrospective analysis of clinical data is often performed by physician-scientists. In such research, the source of clinical data is the patient's medical record; however, medical records are intended for patient care and the data are not systematically recorded for research purposes. We drew on recommendations in the literature and our own experience with a retrospective cohort study that uses a DNA bank to construct guidelines for data collection from medical records. RESULTS: The guidelines incorporate a number of strategies for accurate data collection, which are discussed and illustrated by application. CONCLUSION: With guidelines for data collection, the quality of research data is enhanced. A well-designed case record form and a handbook for standardized data collection are essential for training the data collectors and for ensuring fastidious searching of the record; however, certain kinds of information are not always well documented in patient records. Consequently, it is essential to perform a pilot study to assess the study design and to use additional questionnaires. Correct interpretation of clinical outcomes documented in the medical records often necessitates an independent adjudication committee to prevent bias in outcome definition.

Bias↗

PubMed1999

Compressibility of two polyvinyl siloxane interocclusal record materials and its effect on mounted cast relationships.

STATEMENT OF PROBLEM: Addition silicones (polyvinyl siloxanes) are universally accepted as accurate and stable impression materials. They have also gained popularity as interocclusal record materials. However, it has not been defined if it is possible to work with polyvinyl siloxanes without changing the recorded maxillomandibular relations. PURPOSE: This study examined the compressibility of 2 addition silicones as interocclusal record materials, analyzing the changes of maxillomandibular relations at the condyle region when different compressive forces are used to stabilize articulated casts. MATERIAL AND METHODS: Sixteen interocclusal records, obtained from the same patient (8 of each polyvinyl siloxane, Blu-Mousse, Fast Set), were interposed between the patient casts in a new measuring system obtaining 48 curves of load versus maxillomandibular positional changes in 3 axes (x, y, z). These curves were compared with curves obtained with the casts in maximum intercuspation without interocclusal records (reference curves). Analysis of variance was used to compare maxillomandibular positional changes among the 3 groups (n = 48 each): Blu-Mousse, Fast Set, and control group or maximum intercuspation without interocclusal record. RESULTS: There was no significant change in maxillomandibular relations when forces up to 1 kgf were applied to stabilize the casts related by means of Blu-Mousse and Fast Set addition silicone interocclusal records. CONCLUSION: It is possible to use these polyvinyl siloxanes as interocclusal record materials without changing the recorded maxillomandibular relations.

Analysis of Variance↗