Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “DOCUMENTATION”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 901 records · Page 50Linked to original sources
PubMed1988

Documentation and evaluation of fevers in hospital-based and community-based nursing homes.

We reviewed clinical evaluation practices and documentation of fever (greater than or equal to 100.2 degrees F) in all febrile patients over a two-month period in a hospital-based nursing home (HBNH) compared with a community-based nursing home (CBNH). Results showed 38 febrile (mean 101.9 degrees F) HBNH patients and 26 febrile (mean 101.5 degrees F) CBNH patients. Median time from fever onset to physician contact was 4 hours in HBNH and 12.5 hours in CBNH episodes (P less than 0.01). Laboratory studies were initially performed in 68% of HBNH and 31% of CBNH episodes (P less than 0.005), and diagnosis of fever source was documented in 76% of HBNH and 16% of CBNH episodes (P less than 0.005). Overall assessment stratification showed 81% febrile HBNH patients had both evaluation and therapy performed compared with 38% in CBNH (P less than 0.0001); 39% of febrile CBNH patients had no evaluation or therapy performed. Results indicate lack of documentation, and fever evaluation in CBNHs may preclude complete detection of nursing home-acquired infections and thereby hamper preventive responses to potential infection problems.

Adult↗
PubMed2002

High-speed documented experimental gunshot to a skull-brain model and radiologic virtual autopsy.

The authors documented and evaluated experimental gunshots to a skull-brain model with high-speed photography and subsequent radiographic examination for comparison of the morphologic findings in the model. The artificial skull was a polyurethane ball constructed in layers, with a porous diploe sandwiched between a tabula externa and a tabula interna. The brain itself was simulated with gelatin 10% at 4 degrees C, a material well known in wound ballistics. Gunshots were fired at the model from a distance of 10 m and documented with high-speed photography (up to 50 million frames/sec). Subsequently, a complete examination of the artificial skull was performed, including spiral computed tomography (with two-dimensional and three-dimensional reconstructions) and classic skull autopsy. The high-speed photographs clearly showed the dynamic development of the skull fracture system from an external perspective. The subsequent radiographic examination of the entire head volume created two-dimensional reformations in any plane and three-dimensional reconstructions of the gunshot injury of the polyurethane skull-brain model, especially the wound channel and the fracture system. Thanks to the model and high-speed photographs, the dynamic development of the morphology of a gunshot wound could be documented and studied. The data from computed tomography, using two-dimensional and three-dimensional postprocessing with a perspective view, were very similar to those from classic head autopsy, but derived in a hands-off and nondestructive manner. This examination method leads the way to radiographic digital autopsy or virtual autopsy.

Autopsy↗
PubMed1990

Nursing malpractice: the importance of documentation, or saved by the pen!

Documentation is an elemental to nursing as wound care and vital sign assessment. This article examines the reasons and techniques for accurate and complete documentation in a medical record. Several examples of nursing malpractice involving improper documentation are described. Abbreviations, flow sheets, incident reports, late entries, errors and content are included in the discussion presented.

Humans↗
PubMedDate not supplied

Enhancing documentation for the orthopaedic patient.

A need for integrated, interdisciplinary documentation led to an assessment and evaluation of our current documentation system. This article describes the experiences of a two-hospital health care system in piloting and implementing documentation changes on an orthopaedic unit. Outcomes, conclusions, and a copy of the total joint plan of care are also included.

Continuity of Patient Care↗
PubMed1998

A nationwide prospective surveillance study in Israel to document pediatric invasive infections, with an emphasis on Haemophilus influenzae type b infections. Israeli Pediatric Bacteremia and Meningitis Group.

BACKGROUND AND METHODS: An ongoing nationwide prospective surveillance study was initiated in Israel in October, 1988, to document childhood invasive infections caused by Haemophilus influenzae type b (Hib), Streptococcus pneumoniae and Neisseria meningitidis. This study enabled us to document the effect on childhood invasive Hib disease of the introduction of conjugate Hib vaccines to Israel. RESULTS: The incidence of invasive Hib disease before the age of 5 years dropped from 34 per 100000 before initiation of immunization to < 5 per 100000 in 1995 and is projected to be <4 in 1996. After <2 years, when various conjugate vaccines had been available in the private sector alone and had achieved partial coverage only, the Israeli Ministry of Health decided to add Hib conjugate vaccine to the regular infant immunization program, free of charge, effective for all infants born after January 1, 1994. The vaccine chosen was Hib polysaccharide linked to outer membrane protein complex of N. meningitidis B. Vaccine coverage has exceeded 90% of all infants born since January 1, 1994. Efficacy and effectiveness during the first 34 months of the program (January 1, 1994, to October 31, 1996) were 95.4 and 99.7%, respectively, for all invasive Hib disease and 97 and 99.4%, respectively, for Hib meningitis. CONCLUSION: The described ongoing surveillance program showed the existence and extent of Hib problems in Israel and documented the success of the immunization program in essentially eliminating the disease in Israel.

Child, Preschool↗
PubMed2003

Documenting fusion following anterior cervical surgery: a comparison of roentgenogram versus two-dimensional computed tomographic findings.

Documentation of fusion following anterior cervical surgery may critically influence management strategies that can adversely affect outcome. Would two-dimensional CT studies more accurately identify fusion following single-level anterior corpectomy with fusion compared with radiographic studies (plain/dynamic) alone? To answer this question, two radiologists, in a "blinded" fashion, separately read both radiographic and two-dimensional CT studies obtained 3 and 6 months following 46 single-level anterior corpectomy with fusion. Single-level anterior corpectomy with fusion used nonreversed iliac crest strut autografts and dynamic ABC plates (Aesculap, Tuttlingen, Germany). Following surgery, patients were immobilized in cervicothoracic orthoses, which were discontinued when fusion was confirmed. Patients were followed an average of 3.2 years (minimum 2 years). Outcomes were measured with the Short Form-36 questionnaire administered preoperatively, and 3, 6, and 12 months postoperatively. Three months after surgery, radiographs documented fusion in 38 (83%) of 46 patients, whereas two-dimensional CTs confirmed fusion in only 23 (50%) of 46 patients. Six months postoperatively, radiographs documented fusion in 44 (96%) of 46 patients, whereas only 32 (70%) of 46 patients were solidly fused on two-dimensional CT studies. Three and 6 months following single-level anterior corpectomy with fusion, two-dimensional CT scans more accurately confirmed fusion compared with radiographs alone.

Adult↗
PubMed2004

Informed consent is not routinely documented for procedures using allografts.

Patients who receive musculoskeletal allografts may have severe postoperative infections develop. Media reports have heightened public awareness of the risk of allograft use. Explaining these risks to patients preoperatively has become more important as attention to informed consent issues has increased. This study retrospectively investigated the patterns of informed consent for allograft bone used during elective orthopaedic procedures at a major teaching hospital. Forty-seven (32%) of 148 patients had preoperative discussions of allograft risks and benefits documented with a signed preoperative consent. In nearly 70% of the cases in which structural allograft was used, preoperative consent was documented. Only 8% of cases in which nonstructural, highly processed allograft was used had documented preoperative consent. Forty-eight (32%) of 148 patients were treated with allograft and autograft. Consent was obtained for the harvesting and use of autograft from 90% of these patients. In none of these patients was consent obtained for the allograft used. Although risks of disease transmission vary widely with the degree of allograft processing and the source of its procurement, informed consent for any allograft use should be a routine part of preoperative discussions of risks and benefits in elective orthopaedic surgeries.

Bone Transplantation↗
PubMed2004

ISSLS prize winner: A study of diffusion in human lumbar discs: a serial magnetic resonance imaging study documenting the influence of the endplate on diffusion in normal and degenerate discs.

STUDY DESIGN: An in vivo serial magnetic resonance imaging study of diffusion characteristics in human lumbar discs over 24 hours in healthy volunteers and patients with low back pain. OBJECTIVES: To document the temporal pattern of diffusion in normal human lumbar discs and to study the influence of the vascularity of bone and the status of endplate on diffusion in the normal and degenerate discs. SUMMARY OF BACKGROUND DATA: Diffusion is the only source of nutrition to the discs, but no firm data are available on pattern of diffusion in humans. More data on this important subject are required to improve our understanding of disc degeneration and to probe research possibilities for preventing the same. METHODS: The diffusion pattern over 24 hours following gadodiamide injection was studied in 150 discs (96 normal and 54 degenerate). Signal intensity values for three regions of interest in bone (i.e., vertebral body, subchondral bone, and endplate zone) and seven in the disc were calculated, and normal percentiles of diffusion were derived for these regions. Enhancement percentage for each time period, peak enhancement percentage for each region, and the time taken to achieve peak enhancement percentage (Tmax) were used to define and compare diffusion characteristics and plot a time-intensity curve to document the 24-hour temporal pattern. The correlation of blood flow of the bone as measured by peak enhancement percentage of vertebral body, the status of the endplate zone as measured by the peak enhancement percentage, and Tmax of the endplate zone were correlated with the diffusion of the disc.Univariate analysis of variance, multiple comparisons, appropriate tests for significance, and stepwise linear regression analysis were used for analysis of the data using SPSS software. RESULTS: In normal discs, a "diffusion march" from the vertebral body to the center of disc was noted with the SImax being observed at 5 min in the vertebral body and subchondral bone, at 2 hours in the endplate zone, and at 6 hours in the nucleus pulposus. A significant difference in mean peak enhancement percentage was observed between that of the body and the discs in those less than 10 years and those above the age of 20 years (P < 0.001). Alterations in endplate zone produced distinct magnetic resonance imaging signs of disturbance in diffusion, which offered a reliable noninvasive method of identifying endplate cartilage damage. Stepwise linear regression analysis showed that the significant variable influencing diffusion to the center of the nucleus pulposus of the total sample was peak enhancement percentage of endplate zone (R2 = 0.216; P < 0.001), that of degenerate discs was peak enhancement percentage of endplate zone (R2 = 0.322; P < 0.001), and that of normal discs (R2 = 0.324; P < 0.001) was age. CONCLUSIONS: Serial postcontrast magnetic resonance imaging studies offer a reliable method of assessing the diffusion of the discs and the functional status of the endplate cartilage. Endplate cartilage damage increases with age and produces considerable changes in diffusion. The present study has described reliable signs by which these damages can be identified in vivo. Aging and degeneration have been shown to be two separate processes by documenting clear-cut differences in diffusion. The present data encourage use of diffusion studies as a noninvasive method to assess the physiologic status of the disc and endplate and to study the effect of drugs, smoking, mechanical loading, exercises, etc. on the physiology of the disc.

Adolescent↗
PubMed2001

Automated Braille production from word-processed documents.

This paper describes a novel method for automatically generating Braille documents from word-processed (Microsoft Word) documents. In particular it details how, by using the Word Object Model, the translation system can map the layout information (format) in the print document into an appropriate Braille equivalent.

Algorithms↗
PubMed2004

Anaesthesiological airway management in Denmark: assessment, equipment and documentation.

BACKGROUND: Failed intubation remains one cause of anaesthesia-related morbidity and mortality. In a recent survey in Denmark, 20% of respondents reported preventable mishaps in airway management. METHODS: Assessment of the airway, and its documentation, as well as the availability of various equipment to manage a difficult airway, and the existence of a failed intubation plan were surveyed by mailing a questionnaire to the clinical directors of all 69 anaesthesia departments in Denmark. RESULTS: Fifty-six departments (81%) returned the questionnaire. Pre-operative airway evaluation is performed in 90% of the departments. The tests included the mouth-opening test (77%), Mallampati score (48%), lower jaw protrusion (34%), neck mobility (63%), the measurement of the thyromental (11%) and sternomental distance (4%). The result of the tests are documented by 38% of the departments in the anaesthetic chart (96%), in the record (54%), on a card given to the patient (23%), in a letter sent to the patient's general practitioner (2%) or in a database (13%). The patients are personally informed in 82% of the departments. Only 54% of the departments have a failed intubation plan readily available. CONCLUSION: The preoperative assessment of the airways and its documentation is still unsatisfactory, as is communicating with the patient after a case of a difficult/impossible intubation. The adoption of internationally recognized recommendations might improve airway management and teaching to the best standard possible in the already well-equipped Danish anaesthetic departments.

Algorithms↗
PubMed2005

Macro-video documentation patch tests.

An unequivocal distinction between allergic and irritant patch test reactions is often difficult with patch tests. This study was designed to evaluate the worth of video-macro camera documentation for differentiation between allergic and irritant test reactions and to investigate whether there are characteristic clinical differences in patch test responses between metal salts and fragrances. Patch testing was performed with nickel sulfate, fragrance mix and an irritant, sodium lauryl sulfate 1% aq., on the upper back of 82 patients, with evaluation and computer-aided video documentation after 48 and 72 hr. No reliable clinicomorphological criterion was found for assessing a weak patch test reaction as being definitely allergic. Even characteristic papules and vesicles were not regularly found in allergic reactions. However, unlike fragrance mix, patch test reactions to nickel sulfate were characteristic in that they showed a heterogeneous spread and an association with hair follicle openings, independent of reaction intensity. Evaluation based on additional computer-aided video-macro camera documentation did not add further advantage for the differentiation of allergic and irritant reactions. But well-defined clinicomorphological features and reaction patterns to single test substances or even whole substance categories could be helpful additional criteria for evaluating patch test responses in clinical practice.

Adult↗
PubMed2006

The origin of MDMA (ecstasy) revisited: the true story reconstructed from the original documents.

BACKGROUND: Little is known about the origin of methylenedioxymethamphetamine (MDMA, ecstasy). The most commonly repeated statement in the medical literature is that MDMA was synthesized by the German pharmaceutical company Merck in 1912 in order to develop an appetite suppressor. AIM: To reconstruct the true story of the first known description of MDMA at Merck using the original documents. METHODS: A systematic analysis of the original documents in Merck's historical archive in Darmstadt, Germany, was conducted (years 1900-60). RESULTS: There were no indications for plans to develop an appetite suppressant at Merck between 1900 and 1960. Although MDMA was, in fact, first synthesized at Merck in 1912, it was not tested pharmacologically because it was only an unimportant precursor in a new synthesis for haemostatic substances. The new pathway was patented in order to evade an existing patent by a local competitor. MDMA was called "Methylsafrylamin" in 1912. In 1927 and 1959, the pharmacological effects of MDMA were studied at Merck, but not in humans. DISCUSSION: A systematic analysis of the original documents in the company's archive revealed that uncritical copy-paste procedures may have contributed to the famous myth that MDMA was patented as an appetite suppressor in 1912.

Appetite Depressants↗
PubMed2006

Current hematological findings in cobalamin deficiency. A study of 201 consecutive patients with documented cobalamin deficiency.

With the introduction of automated assays for measuring serum cobalamin levels over the last decades, the hematological manifestations related to cobalamin deficiency have been changed from the description reported in 'old' studies or textbooks. We studied the hematological manifestations or abnormalities in 201 patients (median age: 67 +/- 6 years) with well-documented cobalamin deficiency (mean serum vitamin B12 levels 125 +/- 47 pg/ml) extracted from an observational cohort study (1995-2003). Assessment included clinical features, blood count and morphological review. Hematological abnormalities were reported in at least two-third of the patients: anemia (37%), leukopenia (13.9%), thrombopenia (9.9%), macrocytosis (54%) and hypegmented neutrophils (32%). The mean hemoglobin level was 10.3 +/- 0.4 g/dl and the mean erythrocyte cell volume 98.9 +/- 25.6 fl. Approximately 10% of the patients have life-threatening hematological manifestations with documented symptomatic pancytopenia (5%), 'pseudo' thrombotic microangiopathy (Moschkowitz; 2.5%), severe anemia (defined as Hb levels <6 g/dl; 2.5%) and hemolytic anemia (1.5%). Correction of the hematological abnormalities was achieved in at least two-thirds of the patients, equally well in patients treated with either intramuscular or oral crystalline cyanocobalamin. This study, based on real data from a single institution with a large number of consecutive patients with well-documented cobalamin deficiency, confirms several 'older' findings that were previously reported before the 1990s in several studies and in textbooks.

Aged↗
PubMed1993

Nursing documentation practice on 153 hospital wards in Sweden as described by nurses.

According to Swedish laws and regulations, registered nurses are required to document nursing care in the patient's record. In this exploratory study, nurses were asked to describe how they made their nursing records. The nursing process model was used as a framework. The findings show that a system for admission assessment was fairly common, regarding objectives and a nursing care plan together with a nursing discharge note; more than half of the wards studied recorded these aspects at least occasionally. Nursing diagnoses were seldom recorded in practice. The results reveal serious limitations and deficiencies in the practice of nursing documentation and the implementation of current laws and regulations. This underlines the importance of emphasizing nursing knowledge and nursing documentation in nursing training and practice.

Humans↗
PubMed1993

Nursing care as documented in patient records.

A review of 106 nursing records from 12 wards was conducted to categorize and quantify the content of the documentation and to consider the comprehensiveness of the recording for individual nursing problems. Audit instruments, based on a model for nursing documentation were developed and applied. The results show that admission assessment was missing in slightly less than half of all records, two-thirds had no nursing care plan and about one-third had no documentation on nursing outcome. About 90% of the records had no nursing diagnosis, no objective or no nursing discharge note. Notes on nursing status and nursing interventions were most common. Only one-third of the nursing problems identified had recording that gave information about the progress of the patient's problem. The analyses performed give information on the quality of nursing records which may be used to evaluate the quality of nursing care.

Aged↗
PubMed1991

Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients.

STUDY OBJECTIVE: To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture. DESIGN: The diagnosis of ACS in two prospective clinical studies was compared to its diagnosis in the medical records of the same patients on the same hospitalization. In order to determine if the simultaneous prospective study influences the diagnostic and documentary practices evidenced in the medical records, a further comparison was done by reviewing medical records of two series of patients seen some years prior to the prospective studies. SETTING: Patients with femoral neck fractures treated at a department of orthopedic surgery in a university hospital and one retrospective control sample from a department of general surgery in a county hospital. SUBJECTS: Two prospective samples of patients 65 years and older treated for femoral neck fractures (n = 111 and n = 57, respectively) and two earlier retrospective samples (n = 66 and n = 68, respectively). MEASUREMENTS AND MAIN RESULTS: All comparisons showed that both physicians and nurses diagnosed ACS unsatisfactorily and documented the patients' mental status poorly. The analysis of the two retrospective medical record control samples gave the same results. Neither the physicians nor the nurses used any kind of diagnostic instrument to detect cognitive disorders in the patients. CONCLUSIONS: ACS is a common and severe complication in elderly people treated for femoral neck fractures. Acute confusional states have, by definition, one or more causes that can often be identified and treated. Poor assessment and documentation is a threat to the patients as a correct diagnosis of ACS is a prerequisite for further assessment of its underlying causes and the consequent necessary medical and nursing care.

Acute Disease↗
PubMed2005

Polymerase chain reaction inhibition assay documenting the amotosalen-based photochemical pathogen inactivation process of platelet concentrates.

BACKGROUND: The INTERCEPT Blood System (Baxter Healthcare Corp.) for platelets (PLTs) uses amotosalen-HCl (S-59) in conjunction with ultraviolet A (UVA) light to inactivate contaminating pathogens by modifying the nucleic acids of pathogens. The success of this photochemical treatment (PCT) process can be documented indirectly with a high-performance liquid chromatography assay measuring the photodegradation of amotosalen and measurement of the UVA light dose delivered by the illumination system. STUDY DESIGN AND METHODS: To develop an assay that documents the success of PCT directly on the effector molecule DNA, the effect of PCT on PLT-derived mitochondrial DNA (mtDNA) was examined. mtDNA-specific polymerase chain reaction (PCR) assays were tested with regard to their susceptibility for PCT, their reliability in terms of PCR performance, and the absence of polymorphic sites in primer hybridization loci. RESULTS: Suitable PCR amplification targets were found in the regions of 16S rDNA, cytochrome c oxidase I, and cytochrome c oxidase III of mitochondria. Amplicon sizes between 868 and 1248 bp gave consistent signals before PCT and complete inhibition of the PCR signal after PCT. Amplicons of less than 300 bp were found to be transparent to PCT. CONCLUSION: Based on PCT-mediated mtDNA modifications in PLTs, a PCR inhibition assay was established with a large amplicon documenting the success of PCT and a small amplicon serving as an internal control.

Adenine↗
PubMed2005

Incorporating documents into qualitative nursing research.

PURPOSE: To present an overview of how documents can be incorporated as key sources of data in qualitative nursing research. METHODS: Analysis of the nature of documents and the distinctive features of any research strategy to analyze documents. CONCLUSIONS: Many different strategies can be used in the analysis of documentary sources that are relevant to nursing practice. A systematic approach to the analysis of these textual resources, using one or several of the analytic strategies described here, can support and advance nursing scholarship.

Data Collection↗