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At least 811 records · Page 45Linked to original sources
PubMed1975

[Evaluation and documentation of electronystagmorgrams (author's transl)].

Subsequent to a critical consideration of the ambiguous methods of evaluation and documentation of electronystagmograms (ENG) practised up to now, in particular the butterfly-scheme and the L-scheme, a method is being introduced unequivocally describing the vestibular reaction, on the basis of primary nystagmus functions. Deducted from the theory of rotary nystagmus, this procedure may be transferred to any other experimental vestibular test - taking the knowledge of the primary nystagmus relations for granted - and any ENG registered correspondingly may be documented in the form as described above, and may be reproduced in an idealized state any time. Thus the goal of a documentation in electro-nystagmography, i.e. the most comprehensible recording possible of the information contents of a registered nystagmus, is widely reached. There still remains to insert the speed of the quick phase into the evaluation scheme.

Documentation↗
PubMed2002

Documentation: why is it so important?

Persons who activate an EMS system expect a timely response from people who will be able to help them. When they don't get the service they are expecting, they may look for legal recourse. Hospital staff and healthcare providers expect prehospital care providers to follow protocols and standing orders in providing interventions to help stabilize conditions found during patient assessments. The results of these interventions must be conveyed via both oral and written documentation. Documentation of patient care, equipment maintenance, inventory control and training can help protect the assets of an EMS organization. It can help prove (in a court of law, if necessary) that the organization acted in a prudent manner. Documentation becomes the history of the organization. Does your history show that you are a professional organization?

Documentation↗
PubMed2003

Deduction of principles on long-term conservation of electronically signed documents by multi professional analyses.

Due to actual equalization of qualified electronic signatures with handwritten signatures and the legal acknowledgment of the electronic form, the opportunity to use electronic patient records instead of classic paper-based ones is given. The archiving of medical records over a period of 10 to 30 years represents an important factor in medical documentation which has to be assured for electronically signed documents as well. The ArchiSig project deduces principles on long-term conservation of electronically signed documents and corresponding technical components to be realized by the means of multi professional analyses.

Archives↗
PubMed2003

A conceptual model for documentation of clinical information in the EHR.

At a national level in Denmark the development of a Conceptual Model for Communication in Electronic Health Records (EHR) has moved towards a two-folded structure, i.e. a conceptual model for documentation of clinical information, the Clinical Process, and a Reference Information Model. The coupled structure derived in the final phase of the development of the Conceptual Model for Communication in EHR by the end of year 2001. This was inspired by the in-put and collaboration of several parties in the Danish healthcare sector throughout the period of development from 1999 to the current version 1.01 of the national standard was launched by The National Board of Health in January 2002. The modelling of the Clinical Process meets the need for a more clinical understanding of how the use of information technology, i.e. EHR, can support the work processes of shared-care and continuity of care in hospital settings. The Clinical Process as a model for documentation in EHR facilitates the capturing of clinical information where it emerges in the clinical work processes. The model retains in a logical way the clinical relevant relations between different information elements that comply with the concept of problem-oriented documentation. A comparison between European Pre-standard CEN/ENV 13606 and the Danish Conceptual Model reveals different approaches with regard to the focus of modelling the EHR information.

Denmark↗
PubMed2004

Embedding clinical indicators into nursing documentation.

The Methodist Healthcare System of San Antonio audits completeness and accuracy of nursing assessments. Between 1996 and 2001, regardless of software enhancements and education, completeness of risk assessments hovered at 80% or less. Accuracy of risk scores were in question due to paste functionality. In review, it became apparent that many risk assessment indicators were already an intrinsic part of nursing systems assessment. This project embedded weighted indicators invisibly within systems assessment. Risk scores then automatically calculate and display. This approach decreased documentation queries and increased accuracy of risk assessments. Results were validated using concurrent manual review. Skin assessment demonstrated a 96% accuracy rate with 100% completeness of documentation. Fall assessment resulted in a 2.5% miss rate and 100% completeness of record. 100% of high risk patients identified had appropriate care plan problems. Recommendations are to further explore embedded indicators in software design. The study demonstrated a) decrease in nursing documentation queries b) increase in completeness of record c) increase in accuracy of record and d) increase in accuracy of care plan.

Accidental Falls↗
PubMed2005

[Structured documentation of patients' medical records. A new record structure for emergency admissions is coming].

INTRODUCTION: In recent years a range of efforts to shorten the length of stay (LOS) for patients admitted to hospitals has been tested. Some studies indicate that this might be accomplished by rigorous planning of patient pathways and structured documentation of medical records. In this study the effect of a structured case record model was tested. METHODS: The new record structure was developed using predefined requirements for content, placement and presentation of documentation. Instruction of staff was followed by a switch to the new model from one day to the next. Collection of data was carried out three months before and five to eight months after implementation of the model. RESULTS: The department succeeded in including well over 50% of all includable patients. However, the analysis encompassed all includable patients (''intention to treat'' principle). The number of cases analysed was 340 before and 353 after implementation of the model. Average LOS was reduced by 1.1 day from before implementation to after implementation. This was not statistically significant. However, the model was subsequently kept in use by the department. DISCUSSION: This pilot study shows a non-significant tendency to shotening of LOS by using a structured case record model. It is important to pay attention to the practical difficulties of implementing new documentation tools.

Aged↗
PubMed2005

The case for accurate and complete physician documentation.

While many physicians consider clinical documentation requirements an onerous intrusion into their clinical practice and resent the usurpation of the medical record by billing personnel, the reality is that the pressure for clinicians to perform better in this regard is unlikely to change anytime in the near future. Hopefully, for the reasons outlined in this paper, health care practitioners will learn to rationalize changes in their documentation habits. Quality, profiling and medical-legal outcomes are at stake. Physicians who take pride in their performance must learn how careful attention to accurate and complete clinical documentation will enhance the recognition of their efforts by third party payers, healthcare rating services and the legal system.

Documentation↗
PubMedDate not supplied

E/M documentation pitfalls and audit advice.

This article examines some of the potential problems inherent in the 1995 and 1997 Federal Documentation Guidelines and goes on to give some broad advice regarding documentation of evaluation and management (E/M) services. One small area covered by the guidelines, the history of present illness (HPI), is given some attention as an example of the variability of the guidelines. The use of templates and electronic medical records (EMR) is also addressed in terms of how auditors and regulators would like to see these tools used. A section is devoted to the most important elements of medical record documentation from an auditing perspective. A do's and don'ts section covers common areas of chart deficiencies and focus.

Documentation↗
PubMed2006

Organising European technical documentation to avoid duplication.

The development of comprehensive accurate and well-organised technical documentation that demonstrates compliance with regulatory requirements is a resource-intensive, but critically important activity for medical device manufacturers. This article discusses guidance documents and method of organising technical documentation that may help avoid costly and time-consuming duplication.

Documentation↗
PubMed2006

Good documentation: what it means for your physicians--and your revenue cycle.

To powerfully influence physician documentation behavior--and improve patient care, reduce claim denials, and increase revenues: Examine each physician's documentation and coding habits and history through audits and, if possible, by observing physicians during typical patient encounters. Show physicians how they can improve record-keeping using specific examples from their own practices. Design encounter templates, superbills, and other documentation tools that address individual practice needs.

Documentation↗
PubMed2006

The impact of computerized decision support systems on documentation skills.

The focus of this study is to examine the possibilities of students improving their documentation skills through the use of a Computerized Decision Support (CDS) system. During this ongoing 2 year project, we will assess the CDS used in this study by following 3 classes, where only one is using the CDS. Students, teachers and nurses in practice will be interviewed. Is there a significant difference in the students documentation? The results will presumably provide information about whether the use of a CDS is a support in documentation and in which way. This might have an impact on the pedagogic choices.

Decision Making, Computer-Assisted↗
PubMed2006

Highly automated documentation for mobile medical services.

Mobile Medical Services, such as Home Care and EMS (Emergency Medical Services) are to the general public probably most visible part of public health care. A great amount of expectations are placed on the quality of care given by these units. Sometimes providing this care is very intensive and all available attention has to be placed on the patient. However, documenting the treatment is very valuable for the treatment of the patient later on. In this paper we present a system that automates many tasks in documenting the treatment. Furthermore, our system is capable of producing a far more detailed documentation that has been available before. This makes reliable research of mobile medical care possible and opens new possibilities in educating paramedics and nurses.

Automation↗
PubMedDate not supplied

Preparing documentation for a JCAHO visit.

This article describes a documentation format for Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standard 6. A system for maintaining ongoing documentation is presented. Once in place, only a few "last minute" items need preparation prior to a JCAHO visit. In the weeks preceding the visit, department members can review the materials for accuracy and completeness and ensure that the document adequately reflects the extent and quality of the department's activities. The system is easily adapted to changes in JCAHO standards.

Accreditation↗
PubMedDate not supplied

Flowsheet documentation of chemotherapy administration and patient teaching.

The use of a flowsheet to document chemotherapy administration is an established practice in many oncology settings. Traditionally, these flowsheets have focused on dates of drug administration, drug doses, and laboratory values. In an attempt to simplify documentation of nursing practice related to chemotherapy administration, sections on drug administration, patient teaching, and symptom management were added to the traditional chemotherapy flowsheet in our setting. Development of a standard of care for knowledge deficit related to chemotherapy and standardized patient-teaching materials allowed use of the flowsheet to document patient teaching. This standard also provided consistency and continuity in patient teaching. Additionally, the format of the flowsheet and the charted information has simplified data retrieval for quality-improvement monitoring of some aspects of care.

Antineoplastic Agents↗
PubMed1990

Documenting pharmacists' interventions on a hospital's mainframe computer system.

The development and implementation of a code that enables pharmacists to document their clinical interventions in the hospital's computerized patient records is described. To allow data to be entered in patient records from terminals throughout the hospital that are linked to the mainframe computer, a code was developed to summarize each pharmacist recommendation. The coded information is added to the computer entry for the specific drug requiring intervention. A computer program was developed inhouse for generating daily reports of the pharmacist interventions. During an initial 25-day study period, 300 interventions were documented; house staff physicians accepted the pharmacists' recommendations in 257 (85.7%) of these interventions. An additional 17 (6%) of the interventions resulted from physicians' requests for pharmacists' recommendations. In addition to review of all pharmacist clinical interventions, this system allows review of a specific target drug to determine compliance with institutional drug-use guidelines. Through use of the computer program developed at this hospital, information that documents pharmacists' clinical services can be entered directly into patients' records on the hospital's mainframe computer system and retrieved as useful reports.

Academic Medical Centers↗
PubMed1990

Documentation of referrals: recording bias due to patient insurance type.

This study explores a possible association between the propensity of primary care physicians to record referrals on special referral forms and the source/mechanism of payment for services. Using a randomly selected sample of visits to University faculty family physicians over a 12-month period, referrals were identified from three sources: progress notes, a special form that was included in the patient's chart, and a computerized list that was generated from the special referral form. A notation in one or more of these sources constituted a referral. Using all three sources, the referral rates were 13.8 referrals per 100 patient encounters for Health Maintenance Organization (HMO) patients, compared with 14.1 for Preferred Provider Organization (PPO) patients and 10.4 for patients with other insurance (p = .83). The progress note in the patient chart was the best source for determining whether a referral had been requested, with approximately 85% documentation. Special forms were not likely to be completed for referrals, especially for non-HMO patients (less than 30% documentation). Thus, reliance on a special form for documentation of referrals would have led to the erroneous conclusion of higher referral rates for HMO patients. The tendency of providers to be more complete in recording referrals of HMO patients (a recording bias) may account for the observed higher rate of referral of such patients in other studies.

Adult↗
PubMed1990

[Clinical basic documentation in surgery].

Clinical basic documentation allows a cost lowering and personal saving application of modern data processing technology within the clinical routine. The concept presented in this article has been successful for ten years. Soon after its installation this documentation provides its user with valuable data for internal quality control. Listings of diagnosis, surgical procedures, length of stay and frequencies of complications can be created without extensive knowledge of data processing and computer programming. Based on this concept special documentations for statistical analysis of certain patient groups or diseases are easily established.

Documentation↗
PubMed1989

[Computer-assisted documentation in upper gastrointestinal endoscopy: experiences with routine use at 3 clinics].

The introduction of powerful and inexpensive personal computers (PC) enabled us to develop a documentation system for upper gastrointestinal endoscopy. The system was programmed using the database management system dBASE III. It works on-line, and no computer knowledge or additional staff is needed to run the system. It is now routinely used in the endoscopic units of three different hospitals. Features of performance are a menu-driven data input, automatic report generation and record retrieval, listing according to different criteria as well as other dBASE III facilities. This paper deals with the quality, time effort and user acceptance of the PC-aided system in clinical routine. The analysis showed a good data quality with respect to completeness and adequate use of terminology. Reliability and validity of the documentation were satisfactory considering the methodological problems encountered at their determination. The system was generally judged useful, but time effort was increased compared to conventional documentation.

Documentation↗