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At least 811 records · Page 45Linked to original sources
PubMed1999

[Evaluating the quality of the anesthetic records].

OBJECTIVE: To assess the quality of the anaesthetic record for surgical and non surgical procedures and for elective and emergency surgery. STUDY DESIGN: Retrospective study in a university hospital. MATERIAL AND METHODS: Anaesthetic records collected over one month were analysed. The record included a referential with 38 items: nine for the identification of the patient and those who completed the record, 16 for the preoperative period and 13 for the operative period. Each item was qualified either as present (or correct), or absent, or unreadable or not applicable. RESULTS: Overall, 2,422 anaesthesia records were analysed, including 88,732 items. The mean level of correct items was 72%, and 1% of them were unreadable. Items for identification were significantly more correctly recorded (86%) than those concerning the preoperative (63%) and the operative (73%) periods (P < 0.01). Anaesthetic data for surgical procedures were significantly more correctly recorded (73%) than those for non-surgical procedures (63%) and surgery under local anaesthesia (52%; P < 0.01). Emergency surgical procedures were significantly less correctly recorded than elective ones (70 vs. 72%; P < 0.01). CONCLUSIONS: These results suggest that the quality of the anaesthetic records should be improved, mainly for the preoperative period and for non-surgical procedures.

Anesthesia↗
PubMed1997

Validation of pharmacy records in drug exposure assessment.

The validity of drug exposure measurement based on pharmacy records was investigated taking into account completeness of data, drug compliance, and different methods of drug exposure measurement in pharmacy records. Data on prescription drug use were collected from home inventories and community pharmacies in a survey on drug use and compliance in 115 elderly people. To compare drug exposure in pharmacy records with exposure in the home inventory, three different methods for exposure measurement in pharmacy records were used. Two employed a fixed time window of 30 and 90 days, respectively, and the third method was based on the calculated duration of use of a prescription ("legend time"). Drug exposure in the home inventory was taken as the gold standard and sensitivity, specificity, and positive predictive values of the different methods were calculated for the most frequently used drugs and drug categories. The specificity and positive predictive value of all three methods was generally high (0.93-1.00 and 0.67-1.00, respectively). The 90-day fixed method and the legend time method generally showed high sensitivity (range: 0.67-1.00 and 0.63-0.83, respectively) for drugs that were used on a chronic basis, while the 30-day fixed method had poor sensitivity (range: 0.29-0.69). Drugs that were used according to the home inventory but not according to the pharmacy records methods could be almost completely retrieved in the pharmacy records of a one-year period showing that these records were virtually complete with regard to prescription drugs. We conclude that computerized pharmacy records can be a reliable source of the true drug exposure as estimated in a home inventory, when adequate attention is paid to the definition of the exposure time-window and when these records are comprehensive with regard to prescription drugs.

Aged↗
PubMed2002

Clinical factors and clinical variation influencing the reproducibility of interocclusal recording methods.

OBJECTIVE: The reproducibility of clinical records of the occlusion was assessed in three dimensions using mounted casts. Three distinct areas were examined: 1) mandibular positions (intercuspal position (IP) or retruded contact position (RCP)), 2) materials used in recording the occlusion, 3) clinical variation. DESIGN: Interocclusal records were made in a random order of three patients: one fixed prosthodontics case, one removable partial denture case and one complete denture case, with two different types of waxes, record rims, two different brands of vinyl polysiloxanes and one irreversible hydrocolloid. SETTING: Private practice and Karolinska Institute, Huddinge, Sweden. SUBJECTS: One general dental practitioner and three voluntary patients. RESULTS: Point estimation of variance components indicate that 70-93% of the variation of the positions of the mounted casts are caused by: 1) clinical variation for all three cases and in three directions, 2) the influence of recording materials 0-29%, and 3) mandibular positions (IP/RCP) 0-11%. The ranges of the positions of the mounted casts were lower for the dentate case (0.04-1.39 mm) than for the partially dentate case (0.17-2.65 mm), which in turn was lower than those for the edentulous case (1.42-5.59 mm). CONCLUSION: Clinical variation seems to dominate the variation in positions of mounting casts when making interocclusal records, rather than mandibular position or the recording materials used. Therefore a dentist who makes one single interocclusal record cannot presume that it will reproduce the interocclusal relationship intended, which in the present study was most obvious for the edentulous case. The results showed that impression materials stabilised by a tray did not differ significantly from waxes and record rims concerning the reproducibility. Therefore the stabilised impression materials are an alternative, which also give additional advantages like reduction of appointments as well as superior accuracy.

Aged↗
PubMed2003

Training, quality assurance, and assessment of medical record abstraction in a multisite study.

Clinical studies using medical record review should include careful training and quality assurance methods to enhance the reliability and validity of data obtained from the records. Because of time and budget constraints, comprehensive assessments of data quality and reliability, including masking of medical record abstractors, are not always possible. This paper describes the abstractor training and quality control methods and results of a masked medical record review study. The medical record review study was carried out within a larger multisite study of the effectiveness of screening mammography in preventing breast cancer mortality with an observation period within 1983 and 1993, with mortality follow-up through 1998. An eight-step program was developed to train medical record abstractors and monitor the quality of their work. A key follow-up component to the training protocol was a 5% reabstraction of medical records (n = 160), masked and reviewed by a second abstractor. High agreement was found between initial (unmasked) abstractors and masked abstractors for all key exposure variables (kappa ranged from 0.76 to 0.91), with no evidence of biased directionality by unmasked reviewers. Rigorous ongoing training programs for medical record abstractors provide assurance of good quality control in large multisite studies. Additionally, a masking study with a subsample of subjects may be a feasible and cost-effective alternative to the time- and cost-intensive methodological approach of masking all medical records.

Adult↗
PubMed1994

Maternal recall of birthweights of adult children: validation by hospital and well baby clinic records.

BACKGROUND: Several studies have suggested that maternal recall of offspring birthweight compares well to data from birth certificates or medical records. However, these studies describe relatively short recall periods and pertain to populations where hospitalized childbirth is the norm. Accuracy of maternal recall has not been confirmed after long recall periods or in populations where non-hospitalized childbirth is common. METHODS: Accuracy of recalled birthweights is assessed among 626 women interviewed at an average age of 43.3 years (standard deviation [SD] 1 year), at which time the average age of their 1297 offspring was 17.9 years (range 1-29 years, SD 4.8 years). One-third of these infants were delivered at home. Recalled birthweight was compared to hospital or Well Baby clinic records, available for 66% (861/1297) of all births. RESULTS: Record availability was not related to birthweight. For the 861 infants for whom both sources were available mean recorded birthweight was 3342 g (SD 586 g) and mean recalled birthweight 3340 g (SD 675 g). Recalled weights overestimated recorded weights by 109 g (95% Cl: 68-151) among infants weighing > 3750 g and underestimated recorded weights by 83 g (95% Cl: 54-111) among infants weighing < or = 3250 g. CONCLUSIONS: As an outcome variable recalled birthweights were unbiased, but less precise than recorded birthweights. Use of recalled birthweight does not sacrifice study power however and may increase generalizability provided recalled weights are available for 30% more infants than recorded weights. For individual birthweight assessment and for use as an independent variable recalled weights are biased and may have to be adjusted using recorded data as available.

Adult↗
PubMed1985

A comparison of pregnancy history recall and medical records. Implications for retrospective studies.

Using data from the Diethylstilbestrol-Adenosis (DESAD) Project, a study of the effects of diethylstilbestrol (DES) exposure during fetal life, the authors compared prenatal records with obstetric history from mother's questionnaires completed 10 or more years after the birth of their daughters. Except for the history of hospitalization and trunk x-ray, no differences were observed in agreement (questionnaire compared with record) between the group of DES-exposed mothers identified through review of their prenatal records and the comparison group of mothers who were not exposed. The authors also compared data from mothers of DES-exposed daughters who initiated their own enrollment in the study (walk-ins and referrals). To obtain prenatal records for these women, physicians were contacted. They would usually supply drug exposure data but not the other obstetric history requested. Mothers of these walk-ins and referrals had slightly better agreement between questionnaire and records when compared with the two groups identified by review of prenatal records. In general, there was good to excellent agreement for all groups when mothers' recall of personal history (past miscarriage, past pregnancy, etc.) was compared with their medical records. However, for medical intervention such as drugs and x-rays, agreement was poor. Of the DES-exposed mothers identified through review of their prenatal records, 29% could not remember whether they took DES. An additional 8% said they did not take DES when it was recorded in their charts.

Clinical Trials as Topic↗
PubMed2000

The accuracy of general practitioner records of smoking and alcohol use: comparison with patient questionnaires.

BACKGROUND: General practitioner (GP) records are increasingly being used as sources of information on potential confounders such as smoking use and alcohol intake in epidemiological studies. The aim of this study was to assess the accuracy of GP records on smoking use and alcohol intake compared with data from patient questionnaires. METHODS: Patients registered with 42 practices in Oxfordshire that agreed to take part in a post-marketing surveillance study of omeprazole were sent a postal questionnaire that included questions about alcohol and tobacco use. Two years later, data on these aspects of lifestyle were abstracted from the GP records. RESULTS: A total of 892 patients agreed to take part in the study; 804 (90 per cent) completed the postal questionnaire, and the records of 856 (96 per cent) were reviewed. Information on smoking and alcohol use was present in 74 per cent and 63 per cent of GP records, respectively. Agreement between the two data sources was moderate for both smoking (kappa = 0.50) and alcohol use (kappa = 0.52). With regard to smoking, the main discrepancy between the two data sources was that 46 per cent (94/206) of patients who reported themselves as exsmokers were recorded as being never smokers in the GP record. With regard to alcohol, there were no systematic differences between the two data sources. CONCLUSION: Data from GP records on smoking status and alcohol use are incomplete and subject to some misclassification. This is a source of potential failed adjustment for confounding, which should be considered in epidemiological studies that make use of these records.

Alcohol Drinking↗
PubMed1997

The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia.

BACKGROUND: Electronic anesthesia record keeping (EARK) systems increasingly are used in the operating room, but studies have only recently begun to investigate their effect on anesthesia task performance. Teak analysis, workload assessment, and vigilance assessment techniques were used to study senior residents providing anesthesia for coronary artery bypass graft (CABG) procedures. The impact on anesthesia residents' workload of the routine use of transesophageal echocardiography (TEE) also was examined. METHODS: Before each case, the record keeping system was randomly selected as either electronic (Distek ARKIVE; EARK) or traditional manual recording (MAN). Twenty CABG procedures (10 EARK and 10 MAN) were examined, with observation commencing with anesthetic induction and terminating on initiation of cardiopulmonary bypass. The activities of each resident, divided into 32 task categories (e.g., "laryngoscopy," "observe monitors," etc.), were recorded by a trained observer using a computer. The response latency to a randomly activated alarm light was used as a measure of vigilance ("vigilance latency"). Workload was rated by subject and observer at random 10- to 15-min intervals throughout the case. Data analysis included calculation of workload density (number of tasks/min multiplied by task-specific workload values) and task-links (relationship between sequential tasks). RESULTS: The two groups had a similar distribution of tasks before intubation. In only 4 of the 20 cases studied did any manual record keeping occur before intubation. After intubation, the EARK group spent less time record keeping and using the TEE but more time observing the monitors and conversing with the attending physician than the MAN group did. All subjects reported significantly higher workload scores before intubation compared with after intubation. Similarly, vigilance latency was greater before intubation compared with after intubation (57 vs. 31 s; P < 0.001). There were no significant differences between the two record keeping groups in subjective workload scores, workload density, or vigilance latency. During TEE use, vigilance latency was significantly longer, and workload density was greater than during other monitoring or recording tasks. CONCLUSIONS: This study provides an objective description of the task distribution and workload during the administration of anesthesia for cardiac surgery. Under the conditions of this study. EARK use modestly decreased the time spent record keeping during the postintubation prebypass period. However, there was no effect of EARK either on vigilance or several measures of workload. TEE use was associated with increased workload and possibly decreased vigilance.

Anesthesiology↗
PubMed1992

Self-report versus medical record functional status.

The importance of assessing functional status in the hospitalized patient is gaining recognition. However, the availability and accuracy of medical record functional status data are uncertain. We collected data on 2,504 patients greater than 65 years of age discharged alive. A personal interview conducted 2 days before discharge recorded the patient's self-reported ability to perform 5 activities of daily living scales. Medical record abstraction was used independently to determine ability to perform the same activities of daily living scales. Patients who required any human assistance to perform a function were considered dependent. Patients were also contacted after discharge to determine the site of posthospital care (28% discharged to a nursing home). The amount of missing medical record functional status data varied by function from 20% for bathing to 50% for dressing. Ten percent of patients had no medical record functional status documentation concerning any of the five functions. The prevalence of self-reported dependence at discharge varied by function from 24% for feeding to 93% for bathing. The total number of dependencies differed between the two methods (medical records, 2.3 +/- 1.9; self-report data, 3.2 +/- 1.5). There was exact agreement between the two methods on the total number of dependencies in 28% of cases and differences of greater than or equal to 3 in 20%. In a stepwise logistic model predicting discharge to a nursing home and adjusting for other relevant variables, the number of dependencies as determined by self-report and medical record data each remained significant (Odds Ratios = 1.6). Self-report and medical record functional status data differ substantially, and the medical record data remain independently associated with nursing home placement. Several possible explanations for this finding are explored.

Activities of Daily Living↗
PubMed1995

Estimating immunization coverage from school-based childhood immunization records.

To determine the accuracy of school-based childhood immunization records and to describe the effects of their use on estimates of community-wide immunization coverage, we verified the immunizations to 72 months of age for children born in 1986 to residents in Dallas County, TX, and in Minnesota. Verified immunizations were compared with those documented in the school record. Major transcription errors accounted for fewer than 1% of discrepancies between school and provider records. For 99 subjects with 987 verified immunizations in Minnesota, age-appropriate immunization coverage estimated from the school records was within two percent of actual coverage. For 86 subjects with 981 verified immunizations in Dallas County, age-appropriate immunization coverage from the school records underestimated actual coverage by as much as 21%. The primary factor explaining the underestimate in Dallas was incomplete school immunization records for 33 (38%) subjects and 126 (13%) immunizations. Selective recording of immunizations related to the minimum state requirements in Texas contributed to incomplete school records in Dallas County. Verification of the completeness of records selected to estimate immunization coverage is essential if the estimates are used to monitor trends or to make public policy decisions.

Child↗
PubMed2005

Self-reported diagnostic X-ray investigation and data from medical records in case-control studies on thyroid cancer: evidence of recall bias?

The aim of the present investigation was to evaluate and compare data from medical records with mailed questionnaires concerning risk factors for diagnostic X-ray investigation induced thyroid cancer. This study encompassed 180 patients and 360 controls, selected from the National Population Registry. Information on medical X-ray exposure was obtained by medical records and also from mailed questionnaires, with a latency of 5 years from diagnosis. The mailed questionnaire was answered by 171 cases (95%) and 325 controls (90%). In 132 cases and 251 controls data on medical records were collected and compared with data from mailed questionnaires for the same subjects. No earlier X-ray investigation based upon medical records was reported in 39 cases and in 74 controls. The median cumulative thyroid dose for cases was 1.1 mGy in medical records and in mailed questionnaire 0.6 mGy. For the controls the respective median cumulative dose was 1.0 mGy in medical records and 0.3 mGy in mailed questionnaires. The median ratio between medical records and mailed questionnaires in the cases was 2.1. For the controls the median ratio was 2.9. Wilcoxon's Matched Pairs Test (WMPT) showed a significantly underreport of thyroid X-ray dose in both cases (P<0.01) and controls (P<0.000001). In cases younger than 50 years at the time of the diagnosis of thyroid cancer there was not a significant underreport of X-ray examinations. Corresponding data from the control group showed however a significant underreport. Both cases and controls older than 50 reported significantly fewer X-ray investigations compared with data from medical records. A significant underreport was found among women both in cases and controls. For men there was a slight underreport among both cases and controls, although not significant. In conclusion, when studying diagnostic X-ray investigation as a risk factor for thyroid cancer, it is important to reduce the potential for recall bias when the study relies only on case-control reporting. To complement a case-control study with prospective medical data recorded at the time of the investigation could be an appropriate way to reduce the risk for recall bias.

Adult↗
PubMed2000

Anaesthetists' records of pre-operative assessment.

The pre-operative anaesthetic records of 195 patients were analysed for the presence of 12 agreed core items of pre-operative assessment. This study showed that anaesthetists recorded 26.8 per cent of this information. In up to one-third of patients the following were recorded: smoking history, family history, gastro-oesophageal reflux, airway assessment, dental assessment, chest examination, heart-sounds and blood pressure. Previous anaesthesia, drug history and allergies were recorded in one to two-thirds of patients. Past medical history was recorded in over two-thirds of patients. With a view to improving the level of record-keeping, a formatted, pre-printed pre-operative assessment record was introduced into practice and two months later the audit was repeated. A small but non-significant improvement in record keeping was observed. An argument is made for the introduction of an interdisciplinary, unified anaesthetic pre-operative record.

Adolescent↗
PubMed2004

Is the medical record an accurate reflection of patients' symptoms during acute myocardial infarction?

Documentation of symptoms in the medical record provides clinicians and researchers with valuable information about the patient's experience during acute myocardial infarction (AMI). To examine the consistency between the patient's reported symptoms and the medical record, 215 patients were interviewed and their medical records examined for information about their admission symptoms. Chest pain was the most frequently reported and recorded symptom, and there was good agreement between the patient's report and the medical record. Although fatigue was the second most frequently reported symptom by patients, it was rarely documented in the medical record. Time of symptom onset was identified by 87.9% of patients but only documented in 60.5% of medical records. Clinicians may be recording those symptoms that support the AMI diagnosis and not those perceived to be less relevant. Findings suggest that the medical record is an inaccurate and inadequate source of information about patients' actual experience of AMI symptoms.

Documentation↗
PubMed2006

Evidence for handheld electronic medical records in improving care: a systematic review.

BACKGROUND: Handheld electronic medical records are expected to improve physician performance and patient care. To confirm this, we performed a systematic review of the evidence assessing the effects of handheld electronic medical records on clinical care. METHODS: To conduct the systematic review, we searched MEDLINE, EMBASE, CINAHL, and the Cochrane library from 1966 through September 2005. We included randomized controlled trials that evaluated effects on practitioner performance or patient outcomes of handheld electronic medical records compared to either paper medical records or desktop electronic medical records. Two reviewers independently reviewed citations, assessed full text articles and abstracted data from the studies. RESULTS: Two studies met our inclusion criteria. No other randomized controlled studies or non-randomized controlled trials were found that met our inclusion criteria. Both studies were methodologically strong. The studies examined changes in documentation in orthopedic patients with handheld electronic medical records compared to paper charts, and both found an increase in documentation. Other effects noted with handheld electronic medical records were an increase in time to document and an increase in wrong or redundant diagnoses. CONCLUSION: Handheld electronic medical records may improve documentation, but as yet, the number of studies is small and the data is restricted to one group of patients and a small group of practitioners. Further study is required to determine the benefits with handheld electronic medical records especially in assessing clinical outcomes.

Clinical Trials as Topic↗
PubMed2006

Developing the electronic health record: what about patient safety?

This paper examines the development of electronic health records within the National Health Service (NHS) by an analysis of a series of pilot projects funded by the Electronic Record Development and Implementation Project (ERDIP), one aspect of the work of the NHS Information Authority (NHSIA) (As of 1 April 2005, the NHSIA ceased to operate. Much of its work is continued by Connecting for Health and the Health and Social Care Information Centre.) The focus of the analysis is on the extent to which identifying and correcting error within health records was explored through these projects. The inherent potential for error and resultant impact on patient safety is highlighted, by considering the context of the record, the content of the record and the process of change from paper-based or piecemeal electronic health records to integrated electronic health records. While the process of change highlights issues of data security and access, it is the variability in starting points for different organizations that possibly poses most risk to patient safety. Issues relating to the content of the record can to some extent be minimized by the effective use of technology, but the tension between coding and qualitative data requires further consideration in terms of its impact on patient safety. This paper concludes that the development of electronic health records has to be viewed within the context of governance and patient safety, and the implications articulated.

Diffusion of Innovation↗
PubMed2002

Discrepancies between medical and pharmacy records for patients on anti-HIV drugs.

OBJECTIVE: To compare and evaluate drug notations in outpatient medical records and in pharmacy records in a cohort of HIV-1-infected patients treated with antiretroviral drugs. METHODS: Data on 103 patients were obtained from January 1, 1998, through December 31, 1999, by medical chart review and collection of pharmacy records. Two analyses were performed. First, antiretroviral drugs and comedication in the pharmacy records were documented and compared with their appearance in the outpatient medical records. Second, a detailed comparison was performed at 5 time points during the study period for the antiretroviral drugs. Generic name, formulation, strength, and frequency of dosing as registered in the outpatient medical records were compared with those registered in the pharmacy records. RESULTS: Total drug dispensation was 1607 (366 and 1241 antiretroviral drugs and comedication, respectively). The first screening resulted in a total discrepancy of 55.1% (n = 885), of which 97.1% (n = 859) was attributed to the comedication and 2.9% (n = 26) to the antiretroviral drugs. The discrepancy for the antiretroviral drugs at the specific time points ranged from 5.1% to 12.6% when the generic name only was used, and from 7.1% to 17% when formulation, strength, and frequency of dosing were also taken into account. CONCLUSIONS: The observed discrepancy between outpatient medical records and pharmacy records mainly concerns the comedication. For the antiretroviral drugs fewer, but still substantial, discrepancies were observed. These results indicate that full exchange of information conceming drug use in this population between general practitioners and specialists (infectious disease) is lacking.

Adult↗
PubMed2004

Comparison of methods for handling censored records in beef fertility data: field data.

The purpose of this study was to compare methods for handling censored days to calving records in beef cattle data, and verify results of an earlier simulation study. Data were records from natural service matings of 33,176 first-calf females in Australian Angus herds. Three methods for handling censored records were evaluated. Censored records (records on noncalving females) were assigned penalty values on a within-contemporary group basis under the first method (DCPEN). Under the second method (DCSIM), censored records were drawn from their respective predictive truncated normal distributions, whereas censored records were deleted under the third method (DCMISS). Data were analyzed using a mixed linear model that included the fixed effects of contemporary group and sex of calf, linear and quadratic covariates for age at mating, and random effects of animal and residual error. A Bayesian approach via Gibbs sampling was used to estimate variance components and predict breeding values. Posterior means (PM) (SD) of additive genetic variance for DCPEN, DCSIM, and DCMISS were 22.6d2 (4.2d2), 26.1d2 (3.6d2), and 13.5d2 (2.9d2), respectively. The PM (SD) of residual variance for DCPEN, DCSIM, and DCMISS were 431.4d2 (5.0d2), 371.4d2 (4.5d2), and 262.2d2 (3.4d2), respectively. The PM (SD) of heritability for DCPEN, DCSIM, and DCMISS were 0.05 (0.01), 0.07 (0.01), and 0.05 (0.01), respectively. Simulating trait records for noncalving females resulted in similar heritability to the penalty method but lower residual variance. Pearson correlations between posterior means of animal effects for sires with more than 20 daughters with records were 0.99 between DCPEN and DCSIM, 0.77 between DCPEN and DCMISS, and 0.81 between DCSIM and DCMISS. Of the 424 sires ranked in the top 10% and bottom 10% of sires in DCPEN, 91% and 89%, respectively, were also ranked in the top 10% and bottom 10% in DCSIM. Little difference was observed between DCPEN and DCSIM for correlations between posterior means of animal effects for sires, indicating that no major reranking of sires would be expected. This finding suggests little difference between these two censored data handling techniques for use in genetic evaluation of days to calving.

Animals↗
PubMed1978

Recording of the retruded position of the mandible in patients with mandibular dysfunction.

The precision (reproducibility) of active and passive recordings of the retruded position of the mandible was studied by two examiners on 10 patients with mandibular dysfunction symptoms. The position of the mandible was recorded with an intra-oral graphic method, before and after treatment of the symptoms. The precision of the recording was highest when the retruded position was recorded by passive hinge movement and lowest when it was recorded by active hinge movement and when recording habitual closure. Both systematical and accidental errors tended to be somewhat larger among these patients than that previously found among individuals without signs or symptoms of mandibular dysfunction. The accidental errors in antero-posterior and medio-lateral directions were the same fo both examiners and of the same magnitude before and after treatment of the symptoms. Both examiners recorded the retruded position on the average 0.20 mm more posterior after treatment than before. The results showed that because of its good reproducibility the retruded position of the mandible can be recommended as a reference position in functional analysis of occlusion and for jaw recordings also in patients with TMJ muscle-pain dysfunction symptoms. During the recording the conventional technique with passive hinge movement and a posterior pressure should be used.

Adult↗