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At least 829 records · Page 46Linked to original sources
PubMed1999

[Digital recording in neurosurgery].

The purpose of this study is to examine the image quality of multi-media for digital recording of surgical procedure using an operating microscope in neurosurgery. For video recording, high vision recording, digital video recording and analogue VHS recording were used. For still pictures, an analogue camera with 35 mm silver halide film and a micro-digital camera were used. The quality of photographs taken with a microdigital camera was superior to the quality of those taken with the conventional 35 mm film camera. The micro-digital camera system is superior to the conventional 35 mm camera in neurosurgery in its quality and success rate. In video recording, high vision analogue recording was superior to any other media as far as its image quality is concerned although its practical convenience is limited and cost performance is not always good. On the other hand, digital video can record high quality images, including still pictures, with satisfactory quality to the neurosurgeon. These digital recording media are also space saving for storing the huge amount of data obtained during surgery and the cost-performance is superior to that of the conventional method. In the near future, most of surgical procedures are supposed to be expected using digital media.

Humans↗
PubMed2000

[Does disclosure of medical records to patients influence medical care?].

UNLABELLED: Disclosure of medical records to patients has been assessed, but the influence of disclosure on medical care has not been well researched. To address this situation, this study was conducted to test three hypotheses: 1) doctors think that the disclosure can influence medical care, 2) whether doctors think disclosure can influence medical care depends on how they rank medical records (for example, as evidence for diagnosis and treatment, a process to reach a diagnosis, a tool to communicate with other medical staff, etc), and on whether they think medical record disclosure could change the content of the record. Questionnaires were sent to 881 doctors who work at two hospitals affiliated with N Medical School and K Medical University. RESULTS: Four hundred eighty-eight doctors responded. The findings related to the hypotheses were as follows: 1) Those who answered that the disclosure could have an influence on medical care were 49.1% of the total. 2) There was no relation between how doctors ranked medical records and whether they thought disclosure could influence medical care. 3) Doctors who answered that there were things that they would not be able to write if medical records were disclosed accounted for 73.5% of the total. These doctors answered "yes" significantly higher to the question that the disclosure could influence medical care than others (Odds 3.6, P < 0.01). Doctors who thought they would not be able to enter the diagnosis, the name of the disease for insurance, self-evaluation, information that could be judged and subjective information answered that disclosure could influence on medical care (P < 0.05). It was assumed that disclosure of medical records to patients could change the content of the medical records and that could influence medical care. How to deal with information will become an important issue if records are disclosed.

Attitude of Health Personnel↗
PubMed1975

Medical records-their medico-legal significance.

This article discussed the physician's obligations in record-keeping and current judicial attitude towards the patient's medical record. Physicians are required, both medically and legally, to maintain a current, adequate record for each patient. This established the physician's continuity of care, but it also requires his vigilance and diligence through constant review and surveillance. In the past, the record was exclusively the property of the health care provider. Of late, jurisdictions are decreeing that the health care provider has an absolute right to possession and ownership of the original record only, and the right to the information in the record belongs absolutely to the patient. The physician is liable for the proper maintenance, custody, and storage of the record for the required statutory period. Although the patient can custimarily obtain his record by court order, the courts have also recognized the concept of professional discretion under which a physician may deny the patient access to his medical record if in the physician's judgment he believes it would be to the patient's detriment.

Jurisprudence↗
PubMed1999

Clinical record keeping in patients receiving antibiotics in hospital.

BACKGROUND: Antibiotic prescribing is associated with the growth of antibiotic resistance in micro-organisms. Prescribing therefore needs to be restricted by well-designed antibiotic protocols. Audit of such protocols is only possible if clinical information about infection is properly recorded. OBJECTIVE: To assess the quality of clinical data recording in case notes of patients receiving antibiotics in hospital and to assess the effect of feedback of this information on clinical practice. DESIGN: Four point prevalence surveys. SETTING: Directorate of General Medicine, Dundee Teaching Hospitals NHS Trust. SUBJECTS: Inpatients receiving antibiotics. INTERVENTION: Feedback of results from the first two surveys to clinicians. MAIN OUTCOME MEASURES: Proportion of patients in the Medical Directorate with the recording of an antibiotic indication and the temperature in the case notes before, immediately after, and three months after, feedback of survey results. RESULTS: In each survey one third of patients were receiving antibiotics. The antibiotic indication was recorded in 64% of patients prior to feedback and in 86.5% after feedback (p = 0.004). Three months later this had fallen to 74%. Temperature recording improved between 2nd and 3rd surveys (57% to 86.1%, p < 0.001) and declined to 61% in the 4th survey (p < 0.001). Respiratory infection was the commonest recorded indication for an antibiotic; recording of this indication improved between the 2nd and 3rd surveys but declined by the 4th survey. CONCLUSIONS: Audit and feedback of information about clinical record keeping improves standards but improvements are not sustained. Clinical record keeping must be improved so compliance with antibiotic protocols can be properly audited. An "antibiotic sticker" in addition to immediate concurrent feedback may improve such deficiencies.

Anti-Bacterial Agents↗
PubMed1992

[High quality medical records--high quality medicine].

The medical record is both an indicator of the quality of care, and a means of improving this quality. In addition to being a source of information and a means of communication in the care of patients, the medical record is also becoming a document of increasing legal importance. The content and design of medical records, and how they are kept, should comply with legal requirements. The patients' right to read their own records is well established in Norway. Incomplete records and lack of information will always be held against the doctor in the case of complaints or lawsuits. The medical record provides a good basis for evaluation of care, and a systematic evaluation of medical records, e.g. in groups, is an effective form of medical audit. While the authorities are making an effort to achieve better standardization of medical records, every medical practitioner should do his best to let the everyday use of medical records become an important part of his personal quality assurance.

Humans↗
PubMed2005

Are structured data structured identically? Investigating the uniformity of pediatric patient data recorded using OpenSDE.

OBJECTIVE: OpenSDE is an application that supports structured recording of narrative patient data to enable use of the data in both clinical practice and clinical research. Reliability and accuracy of collected data are essential for subsequent data use. In this study we analyze the uniformity of data entered with OpenSDE. Our objective is to obtain insight into the consensus and differences of recorded data. METHODS: Three pediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared and all recorded findings were classified into one of six categories of difference. RESULTS: Of all findings 22% were recorded identically; 17% of the findings were recorded differently (predominantly as free text); 61% was omitted, inferred, or in conflict with the paper record. CONCLUSION: The results of this study show that recording patient data using structured data entry does not necessarily lead to uniformly structured data.

Humans↗
PubMed1991

'New data from old': epidemiology and record-linkage.

Record linkage in the context of epidemiology refers to the putting together of information (records) on the same person which may have been recorded on different occasions and became part of different data collections. The objective of this article is to provide an overview of the use of record linkage in epidemiology, particularly as it pertains to nutrition and food studies. A short description of epidemiological methodology is provided in order to clarify what epidemiologists expect to achieve by record linkage. A general description of the mechanics of record linkage explains how the methodology relates to the quality of the resulting data sets. The potential impact of the approach of record linkage on epidemiological research is discussed, particularly as it relates to nutritional and other food related studies. Ethical considerations related to record linkage are discussed, and in conclusion the future of record linkage is considered.

Animals↗
PubMed1989

Validity of the medical record for evaluation of telephone management.

The purpose of this study was to determine whether the medical record provides accurate documentation of the telephone encounter. The study was a "blinded" comparison of audiotaped telephone encounters and corresponding medical records; it was carried out in the continuity clinic of a primary care pediatric resident-training program. During their first month of rotation through the outpatient department, 17 PL-I residents received one or two calls made by a "simulated mother" using standardized scripts. Transcripts of these calls and the corresponding written medical records were rated by an examiner unaware of the resident's identity. A standardized instrument was used to measure three aspects of performance: General History Taking, Specific History Taking, and General Management. A percentage of agreement was calculated for each scale, and rating scores of audiotapes and written records were compared. Twenty-seven pairs of audiotape and written documentation were analyzed. The mean percentage of agreement between audiotapes and written records was high: 78% for General History Taking, 78% for General Management, 77% for Specific History Taking. Rating scores of the audiotape and the medical record were significantly correlated for two of the scales: General Management (r = .55, P less than .01) and Specific History Taking (r = .50, P less than .01). Most aspects of the telephone encounter were well documented in the medical record. However, several discrepancies were noted when audiotapes and medical records were compared for the presence of specific items. With the exception of the Specific History Taking scale, there was no correlation between the length of the written record and the percentage of agreement.(ABSTRACT TRUNCATED AT 250 WORDS)

Documentation↗
PubMed1995

An audit of the accuracy of upper gastrointestinal diagnoses in Scottish Morbidity Record 1 data in Tayside.

INTRODUCTION: Scottish Morbidity Record (SMR1) data are coded by trained clerical staff from case records and discharge summaries. They form the basis of many strategic NHS decisions. Their accuracy for upper gastrointestinal (UGI) diagnosis is unknown and the study was undertaken to assess this accuracy in Tayside. METHOD: Patients who fulfilled the following criteria were identified using a record-linkage pharmacoepidemiological database, and their case records retrieved: over 50 years of age, had encashed at least one prescription for a non-steroidal anti-inflammatory drug at a Tayside pharmacy and who had SMR1 records containing one or more symptom/diagnosis codes between January 1989 and December 1991. Medically qualified staff were trained to examine case records and to code UGI diagnoses. They searched the case records for every UGI SMR1 entry for these patients from 1980-1992 and produced re-coded diagnoses (RCD) for each hospital event (admission and discharge), using all the data available in the case records. They also abstracted data on the clinical presentation, investigations and management of patients. Each event was then examined by a single medically qualified researcher who compared the original SMR1 codes with the RCDs. RESULTS: 2,101 patients had a total of 3,764 events in 1989-1991. 317 events were either day case procedures or elective surgery or the case records were not found. They were therefore excluded. Of the remainder, the SMR1 and RCD codes were judged equivalent in 1,608 events (46.6%). However, 1,005 SMR1 events (29.2%) contained a symptom code but no diagnosis code and the remaining 834 (24.2%) were judged suboptimal for other reasons. Of those with a symptom code only, 406 could not be improved upon and were transformed into RCD symptom codes only, 435 were assigned symptom and diagnostic RCDs and 164 were assigned diagnostic RCDs only. In the other 834 events, 279 had one or more diagnoses missing, 425 had one or more diagnoses inaccurate, 23 had both missing and inaccurate diagnoses and 107 were not UGI. Thus 1,433 (41.6%) of UGI SMR1 events could be more accurately coded. Examination of investigation data revealed that coding inaccuracy was not due to diagnostic procedures being carried out after admission. CONCLUSION: UGI SMR1 data were satisfactory in about half of all events. In about a quarter there were symptom codes but no satisfactory diagnosis codes, whilst in another quarter the data were inaccurate. These findings have implications for health care activities and research that use these data.

Aged↗
PubMed1995

Confidentiality of medical records: the patient's perspective.

BACKGROUND: The development of modern information technology and the increasing amount of multidisciplinary teamwork in primary health care mean that the principle of patient confidentiality is becoming difficult to uphold. The debate about confidentiality so far has paid little attention to patients' views. AIM: A qualitative study was undertaken to explore patients' expectations and attitudes concerning confidentiality of patients' medical records in general practice. METHOD: Semi-structured interviews were carried out with 39 patients from one general practice. RESULTS: Patients' expectations diverged considerably from actual practice. The majority of interviewees felt that administrative and secretarial staff should not have access to medical records. Some patients had reservations about a doctor not directly involved in their care having access to their records. They were unaware of the fact that practice staff had ready access to their medical records. Interviewees had particular concerns about recording of nonmedical information in their records, and the confidentiality of computerized records. CONCLUSION: Assumptions of shared doctor-patient definitions of confidentiality, at least in this practice, would be misplaced. It is suggested that explicit negotiations about what is recorded in patients' records would go some way to addressing the discrepancies identified in this study.

Adult↗
PubMed1997

Constructing reproductive histories by linking vital records.

Certificates of 1,449,287 live births and fetal deaths filed in Georgia from 1980 through 1992 were linked to create chronologies that, excluding induced abortions and ectopic pregnancies, constituted the reproductive experience of individual women. The authors initially used a deterministic method (whereby linking rules were not based on probability theory) to link as many records as possible, knowing that some of the linkages would be incorrect. They subsequently used a probabilistic method (whereby evaluation of linkages was developed from probability theory) to evaluate each linkage, and they broke those that were judged to be incorrect. Of the 1.4 million records, 38% did not link to another record. From the remaining records, 369,686 chains of two or more events were constructed. The longest chain included 12 events. Of the chains, 69% included two events; 22% included three events. Longer chains tended to have lower scores for probable validity. The probability-based evaluation of chains affected 3.0% of the records that had been in chains at the end of the deterministic linkage. A greater percentage of records in longer chains were affected by the evaluation. Unfortunately, the small subset of records that were the most difficult to link tended to overrepresent groups with the greatest risk of adverse pregnancy outcomes. Researchers contemplating a similar linkage can anticipate that, for the majority of records, linkage can be accomplished with a relatively straightforward, deterministic approach.

Adolescent↗
PubMed2005

Copy fees and patients' rights to obtain a copy of their medical records: from law to reality.

Patients have a legal right under HIPAA to a copy of their medical records. Personal life-long medical records rely on patients' ability to exercise this right inexpensively and in a timely manner. We surveyed 73 hospitals across the US, with a geographic concentration around Boston, to determine their policies about fees for copying medical records and the expected time it takes to fulfill such requests. Fees range very widely, from $2-55 for short records of 15 pages to $15-585 for long ones of 500 pages. Times also range widely, from 1-30 days (or longer for off-site records). A few institutions provide records for free and even fewer make them accessible on-line. We argue that electronic records will help solve the problem of giving patients access to their own records, will do so inexpensively and in a format more likely to be useful than paper.

Confidentiality↗
PubMed1993

Patient access to records: expectations of hospital doctors and experiences of cancer patients.

The aim of this study was to examine cancer patients' reactions to the offer of access to their medical records, hospital doctors' preconceptions of patient access to medical records and the reality of access to records for both parties. Semistructured interviews were conducted with 32 patients and 21 hospital doctors. Hospital doctors were also shown letters from their department to the general practitioner and asked about any changes they would have made as a result of knowing about patient access to records. The results showed that most patients were able to judge for themselves if they wanted access or not and that patients who chose to look at their records found access to their records helpful and reassuring even if the news was bad. Doctors expected access to records to be harmful to patients but would not have wished to amend many of the letters they had written. Patient access to records can be a safe and useful adjunct to good patient care.

Attitude of Health Personnel↗
PubMed1998

Reference values for self-recorded blood pressure: a meta-analysis of summary data.

BACKGROUND: The widespread clinical use of self-recorded blood pressure measurement is limited by the lack of generally accepted reference values. The purpose of this study was therefore to perform a meta-analysis of summary data in an attempt to determine an operational threshold for self-recorded blood pressures. STUDIES AND METHODS: Seventeen studies, including a total of 5422 subjects, were reviewed. Eight of these 17 studies included both normotensive and untreated hypertensive subjects, while the other 9 reports included normotensive subjects only. Within each study an operational cutoff point between normotension and hypertension was derived by means of the mean+2 SDs and the 95th percentiles of the self-recorded blood pressure in normotensive subjects. These 2 methods were contrasted with 2 other techniques that have been applied in the literature to calculate (1) the self-recorded pressures equivalent to a conventional pressure of 140 mm Hg systolic and 90 mm Hg diastolic by means of regression analysis and (2) the self-recorded blood pressures at the percentiles corresponding to a conventional pressure of 140/90 mm Hg. The latter 2 methods were applied in untreated subjects not selected on the basis of their blood pressure. RESULTS: With weighting for the number of subjects included in the various studies, the self-recorded blood pressure averaged 115/71 mm Hg in normotensive persons and 119/74 mm Hg in untreated subjects not selected on the basis of their blood pressure. The reference values for self-recorded blood pressures determined by the mean+2 SDs (137/89 mm Hg) or the 95th percentile (135/86 mm Hg) of the distribution in normotensive subjects were concordant within 2/3 mm Hg, whereas the cutoff points derived with the regression and percentile methods were considerably lower, ie, 125/79 and 129/84 mm Hg, respectively. CONCLUSIONS: Until the relationship between self-recorded pressure and the incidence of cardiovascular morbidity and mortality is further clarified by prospective studies, a mean self-recorded blood pressure above 135 mm Hg systolic or 85 mm Hg diastolic may be considered hypertensive.

Blood Pressure Determination↗
PubMed1998

Optimum lead positioning for recording bipolar atrial electrocardiograms during sinus rhythm and atrial fibrillation.

BACKGROUND: To date, Holter monitoring has been predominantly utilized in the investigation and monitoring of ventricular arrhythmias and myocardial ischemia. Whether currently employed lead configurations are optimal for recording atrial electrocardiograms (ECGs) is unknown. HYPOTHESIS: This study was undertaken to determine which conventional and novel lead configurations are optimal for recording atrial electrical activity during sinus rhythm and atrial fibrillation. METHODS: Recordings were performed on eight healthy volunteers in sinus rhythm and four patients in atrial fibrillation. Each subject had 10 ECGs of three bipolar and three augmented unipolar leads recorded during supine rest, while rising to upright, and during standing rest, yielding a total of 60 leads (30 bipolar leads). Each tracing was inspected by two observers, and parameters such as P-wave amplitude and duration, whether the P-wave onset was clearly seen, atrial fibrillatory-wave amplitude, and amplitude of noise during standing were scored. RESULTS: Leads recording inferiorly and leftward orientated bipoles provided the best registration of sinus P waves. The P-wave amplitude in the standard bipolar C5 lead (0.12 +/- 0.02 mV) was, however, inferior to others such as recordings between C1 and C6 positions (P-wave amplitude 0.16 +/- 0.02 mV) or from below the right clavicle to the left upper quadrant of the abdomen (0.16 +/- 0.01 mV). Optimal recording of fibrillatory waves was from different leads, such as a bipole from below the left clavicle to a low C1 position (fibrillatory wave amplitude 0.27 +/- 0.03 mV). CONCLUSION: When Holter recordings are performed for the investigation of atrial arrhythmias, nonstandard lead configurations provide superior recording of atrial electrical activity. We advocate the use of electrodes positioned from C1 to C6, from below the left clavicle to a low C1 position, and a vertically orientated lead from the manubium to the twelfth vertebra or the xiphisternum.

Adult↗
PubMed2001

Effect of recording window and stimulation variables on the statistical technique of motor unit number estimation.

A variety of methods are used for the selection of recording window sizes and stimulation current levels for statistical motor unit number estimation (MUNE). This study compares different recording window sizes and stimulation current levels within those windows in the same subjects to determine the effect on MUNE value and reproducibility. Four recording windows of 10% size were compared with four of 5%, with the stimulation current set in the lower quarter, middle half, and upper quarter of the recording window. MUNE for stimulation current set in the lower quarter of the window was 81 (62-103) for 10% recording windows and 120 (108-135) for 5% recording windows, and 91 (61-123) and 133 (120-154) for stimulation current set in the middle half. Increasing the recording window size from 5 to 10% lowers the MUNE value in controls, but tends to improve reproducibility; and setting the stimulation current in the lower quarter of the window, changes the MUNE value minimally, while tending to improve further reproducibility. Excellent reproducibility of MUNE was obtained when applied to a pilot group of 10 amyotrophic lateral sclerosis patients. Based on this study, we conclude that the ideal method for statistical motor unit estimation involves using 10% recording windows and setting the stimulation current in the lower quarter of the recording window.

Adult↗
PubMed1995

Influence of recording site within the muscle on motor unit potentials.

The influence of the recording site on the motor unit potentials (MUPs) was investigated in the brachial biceps muscle of 8 healthy subjects. The MUPs were recorded with a concentric needle electrode and analyzed with a new decomposition EMG program we call multi-MUP analysis. MUPs had shorter durations and smaller amplitudes at superficial recording sites than at deeper sites in the muscle. This is mainly due to the cannula of the concentric electrode, which records a higher potential at superficial recording sites and partially cancels the recorded potentials from the tip in a differential recording. The MUPs had longer durations and higher amplitudes distally than in the middle of the muscle. The longer durations and spike durations are probably due to increased temporal dispersion at a greater distance from the endplate zone. We do not have an adequate explanation for the larger amplitudes distally in the biceps, they may be due to anatomical factors. To increase the diagnostic sensitivity of quantitative MUP analysis the recordings should be obtained from standardized recording sites.

Adult↗
PubMed1991

Endocardial monophasic action potential recordings for the detection of myocardial ischemia in man: a study using atrial pacing stress and myocardial perfusion scintigraphy.

In a study designed to appraise the use of monophasic action potentials (MAPs) to detect myocardial ischemia in endocardial recordings, changes in steady-state MAP duration were compared in recordings between normal and ischemic areas of myocardium identified by the use of a radionuclide tracer simultaneously with the MAP recording procedure. Single-site recordings were made from the left or right ventricular endocardium or both in 26 patients (32 recording sites) during atrial pacing up to angina threshold. Pacing was maintained for 2 minutes at each increment in heart rate and MAPs were recorded at the end of each 2-minute period. Perfusion defects produced by atrial pacing stress were detected using technetium-99m hexakis-2-methoxy-2-methylpropyl-isonitrile injected at peak pacing stress. In 18 recordings from normally perfused areas of endocardium, MAP duration at 70% and 90% repolarization shortened by a mean (+/- SD) of 20.9 (3.7) msec and 22.0 (4.8 msec, respectively, for every 100 msec change in cycle length. This is in keeping with the effect of cycle length changes on the action potential duration. The extent of shortening was significantly greater (p less than 0.01) for 14 recordings from ischemic areas, being 32.0 (8.6) and 33.8 (9.7) msec, respectively, indicating the additional effect of localized myocardial ischemia. These results validate the applicability of the endocardially recorded MAPs for the detection of ischemia. Such methodology may provide a means of assessing therapeutic interventions aimed at the early phase of ischemia.

Action Potentials↗