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At least 91 records · Page 5Linked to original sources
PubMed1989

Longitudinal health record: a pediatrician's viewpoint of the longitudinal health record.

This paper will discuss the Health Record in terms of content, value of a Longitudinal Record, need for a dynamic and interactive record versus the current archived chronological repository of information, areas of application in research, clinical benefits and population related research concerning present and future influences upon a person's health. It will contain the categories of information utilized in a model Health Record, what facts should be contained within a brief Synopsis or Record Abstract and the contents of a master Pediatric Database. Areas of uses, abuses, potential problems, security needs, privacy and confidentiality issues, legal aspects, transfer of information, technical considerations, computerization of the Record and other matters will be discussed.

Adolescent↗
PubMed1998

[Written documentation of drug prescriptions. Accordance between medical records and dispensing records].

UNLABELLED: A comparison of drug prescriptions entered on case records and nurses' drug lists is presented. Of 144 patients admitted to a general internal medicine ward, nine received no drugs. The remaining 135 had 606 (75.0%) items on both case record and drug list, 114 (14.1%) on the case record only, and 88 (10.9%) on the drug list only. For 48 patients (35.6%) drug lists were in accordance with their case record concerning the number and type of drug prescribed. Prescriptions on both documents were characterised by lack of accuracy. Of the 709 prescriptions on case records and 684 on drug lists, 428 (60.4%) and 411 (60.1%) respectively were unambiguous. CONCLUSION: Drug prescribing based on transcription from case records to nurses' drug lists implies a considerable risk of discrepancies. Thus, there is a significant risk of incorrect drug administration. A standardised card for drug prescriptions for common use by both physicians and nurses will therefore now be taken into use.

Adult↗
PubMed1978

Combining final impressions with maxillomandibular relation records in stabilized record bases.

The postinsertion problems of complete denture prostheses are closely related to accurate recording of maxillomandibular relationships. It is essential that these recordings be made with stable record bases; making the final impressions within the record bases prevents movement and tilting. Face-bow and centric relation records properly orient the casts in the articulator. A method to obtain all of these records in one dental appointments has been described.

Dental Articulators↗
PubMed1997

Evaluation of the accuracy of interocclusal records in relation to two recording techniques.

PURPOSE: The accuracy of interocclusal records influences the relationship of the working casts and therefore the success of the prosthesis. The aims of this study were to determine the accuracy of the fit of interocclusal records on the working casts and to compare the accuracy between a classic and modified recording technique, which is described in this article. METHODS: The modified technique uses a metal apparatus that represents opposing arches. Bite registration polyether was used as the recording material and epoxy resin was used as the working cast material. RESULTS: The results indicated that the presence of the recording material produced vertical discrepancies on the interocclusal relationships of the casts. Repositioning or transferring of the records enhanced these discrepancies. CONCLUSIONS: The proposed modified technique reduced the inaccuracies but did not completely eliminate them.

Ethers↗
PubMed2003

Can patients with osteoporosis, who should benefit from implementation of the national service framework for older people, be identified from general practice computer records? A pilot study that illustrates the variability of computerized medical records and problems with searching them.

Although UK general practice is highly computerized, comprehensive use of these computers is often limited to registration data and the issue of repeat prescriptions. The recording of diagnostic data is patchy. This study examines whether patients with, or at risk of, osteoporosis can be readily identified from general practice computer records. It reports the findings of a pilot study designed to show the variability of recording the diagnosis of osteoporosis and osteopenia, as well as how useful surrogate markers might be to identify these patients. The study also illustrates the difficulties that even skilled practitioners in a primary care research network experience in extracting clinical data from practice information systems. Computer searches were carried out across six practices in a general practice research network in the south-east of England. Two of these practices had previously undertaken research projects in osteoporosis and were consequently expected to have excellent data quality in osteoporosis. These two practices had a combined list size of 27,500 and the remaining practices had a combined practice population of 43,000 patients. The data were found to be variable with over 10-fold differences between practices in the recorded prevalence of osteoporosis diagnosis as well as its surrogate markers-such as fragility fractures, long-term steroid prescription, etc. There was no difference in data quality between the two practices that had conducted osteoporosis research and the rest of the group, other than in the areas of diagnostic recording and prescribing for osteoporosis and recording of fractures. Issues were raised by the practices that struggled to identify patients at risk of osteoporosis about the limitations of Read classification in this disease area. Practices need further assistance if the patients at risk are to be identified. Without urgent action, it will be difficult for practices to identify the patients who are likely to benefit from Standard 6-'Falls' of the National Service Framework for Older People. These findings also have broader implications as UK general practice moves towards the implementation of a quality-based contract.

Aged↗
PubMed1998

Single centre open study to compare patient recording of PRN salbutamol use on a daily diary card with actual use as recorded by the MDI compliance monitor.

The aim of this study was to assess the patients' use of inhaled short acting bronchodilators as rescue therapy during a 4-week study period. In this study an electronic metered-dose inhaler compliance monitor (MDI-CM) was used to measure the time and date of actuations of the device and this information was then compared with the patients' self reporting diary card (DC). Salbutamol canisters were used in the compliance monitor. The study was approved by the local ethics committee, and written informed consent was obtained from all patients. Patients aged 18 years and over who were either receiving, or in the investigators opinion required, inhaled salbutamol on a PRN basis were enrolled for a 4-week monitoring phase during which all rescue salbutamol used was obtained from the MDI-CM. Patients were recording their use of salbutamol in the DC each morning and evening. There was a 2-week follow-up period following completion of the monitoring phase or withdrawal from the study. Forty-four patients were enrolled and 35 patients completed the study. The mean age (range) was 43 (20-76) years and mean FEV1 2.32 (0.7-4.0) 1, with male:female ratio of 19:25. Comparison of MDI-CM and DC recordings showed patients fell into three categories: (1) patients who used rescue salbutamol appropriately and whose MDI-CM and DC recordings matched closely; (2) patients who used rescue salbutamol for acute relief but whose MDI-CM and DC recordings did not correlate and (3) patients whose use of rescue salbutamol was inappropriate or erratic according to the MDI-CM but whose DC indicated good compliance. This category of patients include those who 'dumped' all their salbutamol before attending clinic appointments. There was no significant difference in the demographic details or the severity of disease in the three groups. Recorded use of 'rescue' bronchodilator is frequently used as an indicator of efficacy for new anti-asthma therapies. This study comparing electronic data monitoring and remembered rescue salbutamol highlights the potential errors that can occur without accurate recording systems.

Adrenergic beta-Agonists↗
PubMed1996

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion.

OBJECTIVE: The aim of the study was to examine the effect of a computer-generated patient-held medical record summary (CHR) and/or a written personal health record (PHR) on patients' attitudes, knowledge and behaviour concerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patients aged 25-65 years in each practice were randomly assigned to receive either a CHR plus PHR, CHR only, PHR only, or no personal record. Patients were recruited by mail (one practice) or opportunistically by nurses (four practices). Health checks were carried out using the randomly assigned record, which the patient retained. Attitudes to patient-held records, and pre- and post-intervention knowledge and behaviour concerning health promotion, were assessed using questionnaires. Only those who responded to 'before' and 'after' questionnaires were included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitment and 103 from opportunistic nurse recruitment. Patients receiving a CHR as part of mail recruitment were significantly more likely to attend for a health check (P = 0.016). Those receiving both PHR and CHR were more likely to keep (P = 0.014) and use (P = 0.029) the record. Those receiving PHR as part of the package improved their knowledge of health promotion and became more aware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held health summary and an explanatory booklet together is greater than either separately in changing patients' knowledge attitudes and behaviour concerning health promotion.

Adult↗
PubMed1999

The introduction of a woman-held record into a hospital antenatal clinic: the bring your own records study.

We report the introduction of a woman-held record into an antenatal clinic in a NSW teaching hospital using a randomized controlled trial. In 1997, 150 women were randomized to either retaining their entire antenatal record through pregnancy (women-held group) or to holding a small, abbreviated card, as was standard practice (control group). A questionnaire was distributed to women to measure sense of control, involvement in care and levels of communication. Availability of records at antenatal visits was also measured. Women in both groups were satisfied with their allocated method of record keeping, however, those in the women-held group were significantly more likely to report feeling in 'control' during pregnancy. Women in the control group were more likely to feel anxious and helpless and less likely to have information on their records explained to them by their caregiver. The number of records available at each clinic was similar in both groups.

Adult↗
PubMed1991

Reactivity in self-recording: obtrusiveness of recording procedure and peer comments.

Reactivity refers to behavior change that occurs during self-recording without specific programming of consequences. We analyzed the effects of obtrusiveness of recording procedure and peer comments on reactivity to self-recording. Three first-grade students in Experiment 1 completed math questions during a 5-min work period. When we gave the children recording devices and told them to try to complete more questions than the highest number they had previously completed, math performance increased, as did the number of verbalizations about it. Two children showed more reactivity when they used the more obtrusive recording device. Because the increase in math performance corresponded closely to increases in peer comments, we manipulated peer comments directly in Experiment 2. Four second-grade students completed a math task and an alphabet task. Three of the students showed increased math performance during periods when peer comments occurred compared to periods when peer comments did not occur. Although the data from the math task suggested that peer comments can enhance reactivity, we did not observe this relationship with the alphabet task. These results suggest that the conditions necessary to produce desirable results through self-recording are complex and contextually specific.

Auditory Perception↗
PubMed1999

Accuracy of the recording of operative events by the Scottish Morbidity Record 1 (SMR1) for a teaching hospital vascular unit.

OBJECTIVE: To determine the accuracy of operative data collected for the Scottish Morbidity Record 1 (SMR1). DESIGN: Retrospective comparative analysis of operative data recorded by the Scottish Office Information and Statistics Division (ISD) with that recorded in a locally held vascular database where the clinical information was entered by medical personnel. SUBJECTS: All patients with a codeable operative procedure carried out under the care of a single consultant vascular surgeon in a Regional Vascular Unit in 1994. RESULTS: A total of 840 admissions involving at least one OPCS4 code were recorded in the Vascular Database and 793 by the Scottish Office ISD. Although there was good agreement of the total number of operations and admissions, operative codes for 23 patients undergoing major abdominal aortic surgery and 19 undergoing major limb reconstruction were not recorded by the ISD. This represents 14% of total major arterial reconstructions in a single year. CONCLUSION: Accurate data collection has wide implications for research, monitoring future health trends, and planning hospital bed numbers. SMR1 data may accurately record total number of admissions and operations but is poor at distinguishing between those admissions that may be resource-intensive.

Cardiovascular Surgical Procedures↗
PubMed2000

An assessment of the validity of a computer system for probabilistic record linkage of birth and infant death records in Canada. The Fetal and Infant Health Study Group.

Studies on the validity of probabilistic record linkage are sparse. We performed a probabilistic linkage to link the 1984-1994 birth records (obtained from the Canadian Birth Data Base) with 1984-1995 infant death records (from the Canadian Mortality Data Base) in Canada. We extracted the linked birth-death records for Nova Scotia and Alberta (from January 1990 to December 1991) obtained from Statistics Canada's vital registration data and compared them with corresponding records from provincial data (primarily hospital records). The results showed that over 99% of infant deaths (153/155) in the Nova Scotia provincial data were successfully located in the linked Statistics Canada file; the corresponding figure for Alberta neonatal deaths was also 99% (365/367). The distributions of gestational age and birth weight in matched cases demonstrated high agreement between the two data sources. We conclude that the computer system for probabilistic linkage developed by Statistics Canada using the available personal identifying variables in the Canadian Birth Data Base and the Canadian Mortality Data Base is valid.

Alberta↗
PubMed2006

The use of missing birth record data as a marker for adverse reproductive outcomes: a geocoded analysis of birth record data.

Adverse reproductive outcomes (AROs) disproportionately affect black American infants and significantly contribute to the U.S. infant mortality rate. Without accurate understanding of AROs, there remains little hope of ameliorating infant mortality rates or eliminating infant health disparities. However, despite the importance of monitoring infant mortality rates and health disparities, birth record data quality is not assured. Racial disparities in the reporting of birth record data have been documented, and missing birth record data for AROs appears to be disproportionate. Due to the extent of missing birth record data, innovative strategies have been developed to evaluate relationships between maternal socioeconomic status (SES) and community-based ARO rates. Because addresses convey aggregate information about income level, education and occupation, ZIP codes, census tracts and census block-groups have been applied to geocoding efforts. The goals of this study are to: 1) analyze the extent of missing birth record data for New Jersey areas with high rates of an ARO (preterm birth), 2) evaluate associations between the extent of missing birth record data and other AROs, and 3) consider how geocoding strategies could be applied to provide a basis for understanding maternal SES risk factors and ARO resource allocation for at-risk communities.

Adult↗
PubMed1995

Digital optical archiving of medical records in hospital information systems--a practical approach towards the computer-based patient record?

The large number of inpatients and outpatients in university hospitals leads to high costs of medical documentation and to an increasing number of medical documents. Due to legal regulations, these medical records have to be stored for 30 years. This implies spatial, organizational, and economical problems. At present, conventional archiving in hospitals often does not satisfy the need to make medical records available for health-care professionals in a systematic and timely manner. From 1989 to 1993 a pilot study on "digital optical archiving of medical records" was carried out at Heidelberg University Hospital. The study has shown the feasibility of digital optical archiving in hospital s if done under certain conditions. In 1995, Heidelberg University Hospital adopted a procedure for "digital optical archiving of medical records". The digital optical archive will first be filled with the medical records of the department of neurosurgery and the endoscopic and echographic images and reports of the department of internal medicine. It is to be expected that this procedure will gradually lead to an integrated functionality on health-care professional workstations, to a hospital-wide use of an electronic patient record, and to media-independent document management systems. The paper focuses on the potentials of digital optical archiving as an integral part of hospital information systems, and on the requirements for the systematic managements of hospital information systems with respect to digital optical archives.

Archives↗
PubMed2002

Cognitive analyses of a paper medical record and electronic medical record on the documentation of two nursing tasks: patient education and adherence assessment of insulin administration.

The incorporation of electronic medical records into busy physician clinics has been a major development in the healthcare industry over the past decade. Documentation of key nursing activities, especially when interacting with patients who have chronic diseases, is often lacking or missing from the paper medical record. A case study of a patient with diabetes mellitus was created. Well established methods for the assessment of usability in the areas of human-computer interaction and computer supported cooperative work were employed to compare the nursing documentation of two tasks in a commercially available electronic medical record (eRecord) and in a paper medical record. Overall, the eRecord was found to improve the timeliness and quality of nursing documentation. With certain tasks, the number of steps to accomplish the same task was higher, which may result in the perception by the end user that the tool is more complex and therefore difficult to use. Recommendations for the eRecord were made to expand the documentation of patient teaching and adherence assessment and to incorporate web technology for patient access to medical records and healthcare information.

Ambulatory Care Facilities↗
PubMed2006

Vertex-recorded, rather than primary somatosensory cortex-recorded, somatosensory-evoked potentials signal unpleasantness of noxious stimuli in the rat.

In the present study, we investigated in the rat whether vertex- or primary somatosensory cortex-recorded somatosensory-evoked potentials (Vx-SEP/SI-SEP, respectively) signal unpleasantness of noxious stimuli. Therefore, initially we characterised fentanyl effects (0, 20, 40 or 50 microg/kg/h) on somatosensory and auditory processing by recording Vx-/SI-SEPs and vertex- and primary auditory cortex-recorded auditory-evoked potentials (Vx-/AI-AEPs, respectively). Subsequently, in a separate experiment, the animals were subjected to a Pavlovian fear-conditioning paradigm. The noxious stimuli applied to evoke Vx-/SI-SEPs (unconditioned stimulus (US)) were paired to a tone (conditioned stimulus (CS)) under 'steady state' conditions of 0, 20, 40 or 50 microg/kg/h fentanyl. Vx-/SI-SEPs were recorded simultaneously during these trials. After CS-US presentation, CS-induced fear-conditioned behaviour was analysed in relation to the SEPs recorded during CS-US presentation and the AEPs recorded in the first experiment. While the SI-SEP and AI-AEP were minimally but significantly affected, fentanyl dose-dependently decreased the Vx-SEP and Vx-AEP. The decrease of the Vx-SEP and Vx-AEP was parallelled by the dose-dependent decrease of the amount of CS-induced fear-conditioned behaviour. These results suggest that the dose-dependent decrease of the Vx-SEP amplitude, rather than of the SI-SEP, indicates that the US was experienced as less unpleasant. Next to an altered US processing, altered CS processing contributed to the decrease of the amount of CS-induced fear-conditioned behaviour as indicated by the dose-dependent decrease of the Vx-AEP.

Analgesics, Opioid↗
PubMed2004

Analysis of receptive fields revealed by in vivo patch-clamp recordings from dorsal horn neurons and in situ intracellular recordings from dorsal root ganglion neurons.

It has been thought that spinal dorsal horn neurons receive convergent inputs from not only somatosensory but also visceral pathways. For instance, the referred pain is presumed to be due to the convergence of sensory inputs from cardiac and shoulder receptive fields. However, precise investigation has not been made from dorsal horn neurons yet, because of difficulty in studying the pathways from those regions by means of conventional electrophysiology. The purpose of this study is to clarify the convergent inputs to single dorsal horn neurons from wide receptive fields using an in vivo patch-clamp recording technique from the superficial spinal dorsal horn and an intracellular recording from dorsal root ganglion neurons that keep physiological connections with the peripheral sites. Identified dorsal root ganglion neurons received an input from a quite small area, about 1 x 1 mm in width of the skin. In contrast, substantia gelatinosa neurons in the spinal cord received inputs from an unexpectedly wide area of the skin. Previous extracellular recordings have, however, revealed that substantia gelatinosa neurons have small receptive field. This discrepancy is probably due mainly to an availability of the in vivo patch-clamp method to analyze sub-threshold synaptic responses. In contrast, the extracellular recording technique allows us to analyze predominantly the firing frequency of neurons. Thus, the in vivo patch-clamp recordings from dorsal horn neurons and the intracellular recordings from DRG neurons will be useful for well understanding the sensory processing in the spinal cord.

Animals↗