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PubMed1998

Automated key process monitors for patient care documentation.

Complete, accurate and timely patient care documentation is an essential part of the practice of medicine. As with any other process in medicine or industry, continuous quality improvement (CQI) is essential to assure the highest quality at the lowest cost. CQI requires objective key process measures that can be assessed routinely. A set of key process monitors designed to assess completeness, accuracy and timeliness were created based on local, regional and national standards. Feasibility was assessed in the LDS Hospital Emergency Department using 31,429 patient visits in the 18 months from June 1995 to November 1996. The logic of the score was programmed into SQL scripts and run against an Oracle database containing the patient care documentation. The results indicate that the chosen key process monitors can be used to provide real time assessment of the patient care documentation process. The general concepts of the key process measures of completeness, accuracy and timeliness are generalizable to many areas of medicine. The overall score provides one method of easily tracking departmental performance while the overall process monitoring database allows powerful, in-depth analysis of individual components of the process. It is recommended that such automated process monitoring tools be integrated into future clinical information systems.

Data Interpretation, Statistical↗
PubMed1995

Assessment of documented foot examinations for patients with diabetes in inner-city primary care clinics.

BACKGROUND: The established guidelines for a diabetes foot examination include assessing circulatory, skin, and neurological status to detect problems early and reduce the likelihood of amputation. OBJECTIVE: To determine documented adherence with guidelines for foot examinations. SETTING: Four clinics in underserved areas. METHODS: Charts of 350 diabetic patients, identified by billing code, were reviewed for foot examination documentation. A documented foot examination was defined as assessing at least two of the three components of a foot examination. The review determined the periodicity and prevalence of foot examinations, referrals to a podiatrist or vascular surgeon during a 2-year period, and risk factors for foot complications. Stepwise logistic regression was used to determine whether risk factors for foot complications predicted foot examination status. RESULTS: The patients had a mean age and duration of diabetes of 57.7 and 8.8 years, respectively; 86% were black or Hispanic. There was no indication of foot examination or referral for 55.7% of the patients during the 2-year period. Patients with foot care referrals were more likely to have foot examinations by their primary care providers (P = .0001). There was almost a fourfold increase in the odds that patients with diagnosed peripheral vascular disease had foot examinations, with twofold greater odds for each 25-year increase in age. CONCLUSIONS: Populations at risk of diabetic complications are unlikely to have foot examinations in their primary medical care, but having peripheral vascular disease increases the likelihood. Efforts are needed to improve adherence to foot examination guidelines for patients with diabetes from underserved populations.

Ambulatory Care Facilities↗
PubMed1989

Documentation of students' clinical reasoning using a computer simulation.

Computer simulations can provide both a clinical experience for teaching problem solving and a method of documenting a student's clinical reasoning style. The CAMPS simulation consists of approximately 500 items describing a patient's history, physical examination and laboratory results, and treatments. The student has full option to select any item in any order, producing a wide variation of performances. Since all of the students interact with the same clinical problems, the faculty member can make comparisons of that individual student with the class. From the record of the simulation encounter, the person responsible for student evaluations can prepare a narrative that lists the overall performance, the specific omissions and commissions, and comparisons with the class. Experience with a group of 111 students in a basic pediatric course showed that this method of documenting clinical inquiry detected a variety of levels of performances. Comparisons of the results of these tests with the faculty observations showed that 16% of these students who were judged to be very good or excellent in problem solving by the faculty performed at least 1 SD below the class average on the simulations. This project highlights the power of computer simulations to provide documentation of student performance with the additional benefit of a cost of less than $1 per student.

Clinical Competence↗
PubMed1992

The pediatrician's documentation of child maltreatment.

Pediatricians are increasingly involved in the assessment of suspected child maltreatment. These assessments are a crucial component of the overall evaluation of the patient and provide the basis for interventions to protect the child. An accurate documentation of the pediatrician's assessment is important to convey the information to professionals in the public agencies involved, including the legal system. However, there may be uncertainty among pediatricians concerning what should be documented in the medical record in cases of child maltreatment. The objectives of this article are to provide a detailed but generic description of the information that should be gathered during the evaluation of children who show signs of any form of child abuse and neglect and to provide clear guidelines for the proper written documentation of child maltreatment.

Child↗
PubMed2006

First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults.

CONTEXT: Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA. OBJECTIVE: To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes. DESIGN, SETTING, AND PATIENTS: A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36,902 adults (> or =18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36,902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36,902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11,963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24,987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32). CONCLUSIONS: In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.

Adolescent↗
PubMedDate not supplied

Lamination of fragile documents as preliminary intervention to aqueous mass deacidification. A study on reversibility effects.

Paper lamination is a widely known method to consolidate fragile and brittle documents. Since the loss of mechanical strength of paper documents is almost completely due to their acidity, the procedure generally adopted by restorers consists of an aqueous treatment of deacidification followed by consolidation. The drawback of this method is due to the loss of paper fragments during the deacidification step, that must be therefore accurately controlled. Some preliminary experiments showed that a better and faster practice would be the lamination of paper documents with a water-resistant sheet before their immersion in the deacidification bath. The aim of this work is to evaluate the permeability, chemical stability and reversibility of the lamination sheets coated with two commercially available acrylic resins. From both gravimetric and FTIR analyses it appeared that slight modifications of the acrylic monomers led to different properties, and this behaviour can be exploited to improve the properties of lamination sheets in order to set up a reliable method of aqueous mass deacidification.

Acids↗
PubMed1992

Scintigraphic documentation of an improvement in hepatobiliary excretory function after treatment with ursodeoxycholic acid in patients with cystic fibrosis and associated liver disease.

We have previously documented that ursodeoxycholic acid exerts a beneficial effect on liver function and bile acid metabolism in patients with cystic fibrosis. We hypothesized that the mechanism of action may be related in part to the choleretic properties of the administered bile acid. We therefore compared hepatobiliary scintigraphic images obtained before and 1 yr after initiation of ursodeoxycholic acid therapy to document an improvement in bile flow in 13 patients with cystic fibrosis and hepatobiliary involvement. Before therapy, hepatobiliary scintigraphy documented biliary stasis with retention of the isotope in intrahepatic and extrahepatic bile ducts in nine patients; during therapy, duct dilatation decreased substantially in eight patients, with decreased intrahepatic retention and more rapid biliary outflow of the tracer. The time of appearance of isotope in the intestine decreased (from a mean of 36.9 +/- 17.8 min to 18.8 +/- 9.0 min; p less than 0.01) in all patients in whom it had been abnormal, and the half-time of hepatic washout decreased from a mean of 35 +/- 20.7 min to 26 +/- 15.6 min (p less than 0.05). During ursodeoxycholic acid administration enrichment of bile was achieved, with the mean ursodeoxycholic acid percent composition increasing from 5.8% +/- 2.9% to 35.7% +/- 8.5%. Ursodeoxycholic acid became the predominant bile acid in serum. Liver function improved in all 10 of the patients with abnormal values at baseline. We conclude that hepatobiliary scintigraphy is of value in monitoring the therapeutic responses of cystic fibrosis patients with liver disease to ursodeoxycholic acid therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2001

Quantifying and documenting prior beliefs in clinical trials.

Collecting and documenting subjective prior beliefs from knowledgeable clinicians about the potential results of a clinical trial has many advantages. Two large trials of prophylactic treatments in an HIV-positive population are used as examples. The trials recruited patients of primary care physicians and compared treatments which were in use in clinical practice. Opinions about these trials were elicited from 58 practising HIV clinicians. It is shown how the documented opinions can be used to augment the monitoring process; the prior opinions are updated with interim data using approximate Bayesian methods to give posterior opinions incorporating interim results. These posterior opinions can be used by the monitoring board to anticipate the clinicians' reaction to the results. Eliciting prior beliefs is also ethically important for documenting the nature of the uncertainty or equipoise. Important information is provided for the informed consent process and Institutional Review Board (IRB).

AIDS-Related Opportunistic Infections↗
PubMed1996

Comparison of reflectance and transmission densitometry, using document and laser scanners, for quantitation of stained Western blots.

The quantitation of stained Western blots by reflectance and transmission scanning was explored using a blot of monoclonal immunoglobulin G probed with anti-mouse antibody. The so-called "scanned absorbance" output from a document scanner was found to be directly proportional to the fraction of light absorbed rather than obeying the logarithmic relationship expected for true spectrophotometric absorbance. This explains observations in the literature of a strongly curved relation between loading and "absorbance." Laser transmission densitometry of a blot immersed in a clarifying solvent mixture showed that peak area was linearly related to loading over a wide range. In reflectance mode the document scanner also gave equally linear quantitation of dry blots, providing that a logarithmic correction curve was applied during scanning. It was found advantageous to interpose a red acetate filter sheet between the blot and the scanning table to aid detection of weakly stained bands. The document scanner gave less satisfactory results when used in transmission mode on a clarified blot because weak bands were poorly quantitated.

Animals↗
PubMed1995

Documentation of abdominal exploration during laparoscopic cholecystectomy.

UNLABELLED: To assess the documentation of intraperitoneal exploration and events during laparoscopic cholecystectomy, we reviewed 200 dictated operative reports from eight different institutions. The 200 laparoscopic cholecystectomies were performed by 40 different surgeons on 158 female patients and 42 male patients. A description of the gallbladder was included in 134 (67%) reports and not mentioned in 66 (33%) reports. Fifty-four (27%) reports did not mention any intraperitoneal findings away from the gallbladder. Another 36 (18%) of the reports contained only a general comment indicating that no abnormalities were seen in the abdomen (excluding the gallbladder). The other 110 (55%) reports mentioned at least one specific site or finding in the abdomen other than the gallbladder. The most commonly mentioned sites were the liver, bowel, and stomach. Only 42 (21%) operative notes described what happened to the gallbladder contents: 30 described spillage of bile and/or gallstones and 12 stated that no spillage occurred. CONCLUSIONS: Laparoscopic cholecystectomy operative notes have often lacked a description of gallbladder appearance, documentation of abdominal exploration, and/or documentation of complete removal of the gallbladder and its contents.

Abdomen↗
PubMed1981

Documentation of change in problem behaviors among anxious and hostile-aggressive children enrolled in a therapeutic preschool program.

A relatively simple, straightforward procedure is utilized to identify and document changes in problem behaviors among children enrolled in a therapeutic preschool program. Results of two outcome measures indicated a significant overall reduction in problem behaviors for the total group. When subgroups of anxious and hostile/aggressive children were considered, however, there was a significantly greater probability that anxious children would benefit more from the program than hostile/aggressive children. The need to consider subgroups of patients when documented treatment effectiveness is emphasized, and the advantage of building documentation techniques into the record-keeping system is discussed.

Aggression↗
PubMed1986

Automated nursing documentation: a design perspective.

The concept of an automated nursing documentation system has been subject to casual debate for a number of years. During this time, Hewlett-Packard developed a system that is both adequate and workable from many perspectives (i.e. the Staff Notes Subsystem of the Patient Data Management System-PDMS). This package has been used as the primary method to document patient care for six years in the Critical Care Units of Phoenix Baptist Hospital. With the aid of Baptist Hospitals and Health Systems (BHHS) Design Engineers, it continues to evolve predicated on a singular intent: To provide the type of documentation required by the medical staff. The objective of this paper is multifold. Foremost, generalized criteria are established to provide a vehicle for standardizing the design or evolution of a staff notes package. The generic structure of the PDMS notes subsystem is discussed in regard to its parity with these criteria. Finally, custom modifications and additions to this package will be presented, and recommendations for future enhancements will be outlined.

Database Management Systems↗
PubMed1990

Marburger concept for computer-aided acquisition, processing and documentation of patient data in the intensive care unit.

The authors report on their experience with the computer-aided acquisition, processing and documentation of patient data in an intensive care unit. The goal of an effective data and information collection system in the intensive care unit is to make therapy, and the patients respond to it, recognizable and understandable through the clear and complete representation of the patients conditions. The focal point of the data documentation is the medical record. In the implementation of a computer-aided data documentation and processing system the application of one central PC is unpractical. Each bed will be equipped with its own PC, and all the individual PCs will be connected to one central PC, which functions as server, and to connected to another PC in the doctors room. The data will be managed in a powerful database-management-system and be stored on an optical-disk. The development of an effective man/machine interface is especially important. In addition we can promote the user acceptance in other ways, so as to ensure a concrete benefit for each user group.

Electronic Data Processing↗
PubMed1999

[Importance of computer-based procedures. Planning and documentation in orthopedic surgery].

The demand for efficiency in OR management and increase in the necessity of surgical documentation require the use of software applications in hospitals. A client-server based OP-planning and documentation system has been in use in the department of orthopedic surgery in Giessen University since 1992 and is being continuously further developed. Aside from the lawful requirements, the demands of clinical doctors have been especially considered. The main functions are management of non medical patient data, scheduling and documentation of operations with coding of diagnoses and therapy, tissue banking, implant inventory, on call scheduling, storage of medical video images, clinical word processing and e-mail. With an integrated web-server, MedXS has the capabilities to offer functions accessible over any webbrowser (Netscape, Internet-Explorer) in the internet or intranet. Through the usage of this application clinical procedures could be more efficiently realized and better agreeing positions with the insurance companies could be reached.

Humans↗
PubMedDate not supplied

Early detection of chronic disseminated Candida infection in leukemia patients with febrile neutropenia: value of computer-assisted serial ultrasound documentation.

Computer tomography (CT) is known to be as sensitive as magnetic resonance imaging (MRI) in detecting fungal microabscesses in chronic disseminated candidiasis. However, all imaging techniques have to be repeated in cases of suspected fungal infection. Therefore, use of the CT or MRI scan is limited. Only ultrasound (US) examinations can be repeated as often as needed. The disadvantage of US is a lack of sufficient documentation. We analyzed the value of computer-assisted documentation in serial ultrasonography of leukemia patients with suspected chronic disseminated candidiasis. From November 1996 until October 1997, a total of 220 ultrasound examinations (Kranzbühler Logiq 500, 3.5 MHz convex array) were performed in 58 patients undergoing intensive chemotherapy. Initial US pictures were stored on a personal computer and compared with the live US at the time of reevaluation in cases of persistent fever. Ultrasound detected microabscesses in liver and/or spleen in eight of the 58 patients. Diagnosis was confirmed by autopsy/biopsy (n = 6), blood culture (n = 1), and a significant Candida antibody titer (n = 1). Focal lesions occurred only after neutrophil recovery. However, a newly evolving nonhomogeneous, micronodular pattern of liver and spleen occurred during febrile neutropenia in three patients, and two of these developed focal lesions subsequently. Follow-up was easy, since US pictures could be compared directly with stored examinations on screen. We conclude that serial US is sensitive in detecting microabscesses in the liver or the spleen. Computer-assisted US documentation proved to be a helpful tool for detection as well as in the follow-up of patients with chronic disseminated candidiasis.

Adolescent↗
PubMed2006

Development and application of a video-mosaic survey technology to document the status of coral reef communities.

The recent decline in the condition of coral reef communities worldwide has fueled the need to develop innovative assessment tools to document coral abundance and distribution rapidly and effectively. While most monitoring programs rely primarily on data collected in situ by trained divers, digital photographs and video are used increasingly to extract ecological indicators, provide a permanent visual record of reef condition, and reduce the time that divers spend underwater. In this study, we describe the development and application of a video-based reef survey methodology based on an algorithm for image registration and the estimation of image motion and camera trajectory. This technology was used to construct two-dimensional, spatially accurate, high-resolution mosaics of the reef benthos at a scale of up to 400 m(2). The mosaics were analyzed to estimate the size and percent cover of reef organisms and these ecological indicators of reef condition were compared to similar measurements collected by divers to evaluate the potential of the mosaics as monitoring tools. The ecological indicators collected by trained divers compared favorably with those measured directly from the video mosaics. Five out of the eight categories chosen (hard corals, octocorals, Palythoa, algal turf, and sand) showed no significant differences in percent cover based on survey method. Moreover, no significant differences based on survey method were found in the size of coral colonies. Lastly, the capability to extract the same reef location from mosaics collected at different times proved to be an important tool for documenting change in coral abundance as the removal of even small colonies (<10 cm in diameter) was easily documented. The two-dimensional video mosaics constructed in this study can provide repeatable, accurate measurements on the reef-plot scale that can complement measurements on the colony-scale made by divers and surveys conducted at regional scales using remote sensing tools.

Algorithms↗
PubMedDate not supplied

In pursuit of excellence: quality assurance, documentation, and peer review by home birth CNMs.

The unique characteristics of home birth practice for certified nurse-midwives (CNMs) are applied to a quality assurance program. This article explores the mUltiple purposes, benefits, and elements of documentation as they specifically apply to home birth. The steps of documentation for a home birth practice are outlined and the three current models to consider in setting up positive peer review programs in which CNMs can succeed and learn are presented. Recommendations are made for 1) a more positive emphasis on the purposes of documentation and collection of statistics, 2) networking to close the gaps of isolation and task duplication for home birth CNMs, 3) ongoing development of models for positive peer review to facilitate participation in the mandate of the American College of Nurse-Midwives, and 4) identification of clinical indicators for quality assurance specific to home birth practice by CNMs.

Female↗
PubMed2005

Teaching residents coding and documentation: effectiveness of a problem-oriented approach.

OBJECTIVE: We sought to assess the effectiveness of a problem-oriented approach to teaching residents accurate coding and documentation of ambulatory gynecology visits. STUDY DESIGN: This was a pilot before-and-after study. Nine resident volunteers underwent 4 individual instructional sessions on coding and documentation with a trained faculty member over 6 weeks. Outcomes were assessed by comparing the appropriateness of procedure and diagnostic codes billed in participant continuity clinic prior to and in the 6 to 9 months following the intervention. RESULTS: Following the intervention, participants demonstrated an increase in the accuracy of coding the correct category of the evaluation and management service, an increase in the appropriate use of modifiers, and a decline in undercoding errors. CONCLUSION: Problem-oriented interactive learning appears to be an effective method of teaching residents proper coding and documentation.

Feasibility Studies↗