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PubMedDate not supplied

Effectiveness of documented assessment of postoperative pain.

Documented assessment of pain does increase patient satisfaction in pain control and treatment but it must be carried out regularly and, more importantly, it must be acted upon. Patients who participate in documented assessment of pain postoperatively may find it easier to communicate their pain levels to the nurse, may feel more informed about their treatment and may be given analgesia more quickly than a control group. Nurses are aware of the importance of pain intensity assessment but do not always assess the effectiveness of the analgesia given. Each individual's perception of pain is unique and the desired amount of relief from pain is infinitely variable. Pain cannot be treated or controlled if it is not accurately assessed. Any information given before surgery decreases anxiety levels and therefore lessens the patient's perception of pain postoperatively, particularly when the information is related to how and where the patient may feel pain. The use of documented pain assessment combined with patient-controlled analgesia systems may be the key to effective postoperative pain control.

Adult↗
PubMedDate not supplied

The documentation of wounds in an acute hospital setting.

This article presents the findings of research into the documentation of wounds healing by secondary intention, in an acute hospital setting. The benefits of recording the nursing assessment of a patient's wound, together with the legal and professional implications of poor documentation, are outlined. The points that specialists writing on the subject identify as necessary when describing a wound within the nursing records are highlighted. A survey is described in which descriptions of wounds healing by secondary intention were collected from the nursing records on six acute wards in a hospital, and then measured against an assessment tool. For each criterion selected for investigation, the number of occurrences was recorded, thus providing a quantitative description of the documentation of wounds. The findings indicated deficits in many of the areas selected. While statements such as 'healing well' were commonly used, descriptions which would provide information about the state, progress or management of the wound were generally omitted.

Acute Disease↗
PubMed2002

Exploring documentation of end-of-life care of children with cancer.

This article presents the findings of a study that explored documentation surrounding the end-of-life care of children with cancer. An in-depth history audit of 18 children with cancer, who died from disease progression at a single tertiary paediatric centre during 1999, was performed to explore the extent and the ways in which the shift from cure to palliation was reflected in the child's medical record. The study found that while physical aspects of care were documented there was little evidence of the human-to-human aspects of care or processes of decision-making when cure was no longer a possibility. Relapse and disease progression were identified as critical junctures for families and health professionals and an important area for future research. Further, the medical records documented ill-defined periods of palliation, with the child's approaching death appearing as a gradual awareness rather than a distinct shift in goals of care from cure to palliation.

Adolescent↗
PubMed2006

Integration of scanned document management with the anatomic pathology laboratory information system: analysis of benefits.

Electronic document management systems (EDMSs) have the potential to improve the efficiency of anatomic pathology laboratories. We implemented a novel but simple EDMS for scanned documents as part of our laboratory information system (AP-LIS) and collected cost-benefit data with the intention of discerning the value of such a system in general and whether integration with the AP-LIS is advantageous. We found that the direct financial benefits are modest but the indirect and intangible benefits are large. Benefits of time savings and access to data particularly accrued to pathologists and residents (3.8 h/d saved for 26 pathologists and residents). Integrating the scanned document management system (SDMS) into the AP-LIS has major advantages in terms of workflow and overall simplicity. This simple, integrated SDMS is an excellent value in a practice like ours, and many of the benefits likely apply in other practice settings.

Clinical Laboratory Information Systems↗
PubMed2004

Use of transesophageal atrial pacing for documentation of arrhythmias suspected in infants and children.

Transesophageal atrial pacing study was used to document arrhythmias in 67 infants and children age 2 months to 16 years (mean, 8.3 years), who had palpitations or symptoms suggesting tachyarrhythmias but had no electrocardiographic documentation of cardiac dysrhythmias. The transesophageal pacing and medical records were reviewed retrospectively. In 47 of 67 (70%) of the infants and children with suspected tachyarrhythmias, transesophageal atrial pacing induced various tachycardias, which may be the cause of symptoms. In 10 of 67 patients, tachycardia was induced during infusion of isoproterenol. During the study, tachycardia was initiated in 14 of 15 patients less than < 6 years-old and in 33 of 52 patients > or = 6 years-old (P < 0.05). Of these induced tachycardias, 25 of 47 were atrioventricular reciprocating tachycardia, 16 atrioventricular nodal reentrant tachycardia, and 6 idiopathic left ventricular tachycardia. Both transesophageal study and invasive electrophysiologic study were performed in 10 patients. The mechanisms of tachycardia in the invasive study and transesophageal study were identical except for one patient. In conclusion, transesophageal atrial pacing and recording was less invasive, safe and useful for documenting arrhythmias in infants and children who had symptoms suggesting tachyarrhythmias, especially in patients < 6 years of age. Evaluation of the mechanism of induced tachycardia provided useful information regarding the prognosis and therapeutic options in infants and children.

Adolescent↗
PubMedDate not supplied

[Patient autonomy and information and clinical documentation-related rights within the context of Spanish Law 41/2002].

Law 41/2002 Regulating Patient Autonomy and Health Documentation and Information-Related Rights and Obligations regulates matters which the General Health Law of 1986 had fallen short in its attempt to regulate, such as the right to health information, informed consent, health documentation, clinical records and other clinical information. This Law likewise classifies the ways in which capabilities may be limited and attributes physicians with authority over the evaluation thereof. In keeping with the Oviedo Convention on Human Rights and Biomedicine, this study includes the guiding principles of the new bioethics, such as an individual's right to privacy of the health-related information, living wills (or advance medical directives), the patient's right to antonomy and to take part in the decision-making process, the refusal of treatment or teenagers being of legal age for health-related decision-making purposes. Said Law, a primary law nation-wide, means a major advancement in physician-patient relations and must be further expanded upon with regard to numerous aspects thereof by the Autonomous Communities. This study is aimed at describing this body of law and at analysing the repercussions thereof on citizen relations, health professionals and the National Health System as regards the matter of clinical documentation and information.

Confidentiality↗
PubMed2002

Skeletal muscle metastases at sites of documented trauma.

OBJECTIVE: Hematogenous metastases to skeletal muscles have been reported to be rare. We report eight biopsy-proven cases of skeletal metastases occurring in sites of previously documented skeletal muscle trauma. We retrospectively reviewed MR imaging examinations obtained at a large orthopedic surgical oncology service from January 1994 through December 2000 for biopsy-proven metastases to skeletal muscles. Our retrospective review revealed 28 patients with biopsy-proven skeletal muscle metastases. Of these 28 patients, eight had a documented clinical history of previous trauma at the site of skeletal metastasis. Five of these eight patients underwent MR imaging before the development of a metastasis. MR imaging revealed a hematoma in three of the five patients and a partial muscle tear in two of the five patients. The hematomas and partial muscle tears were in the same skeletal muscle location in which the metastatic disease subsequently developed. Metastatic disease was documented by MR imaging and subsequent biopsy. CONCLUSION: Skeletal muscle injury may alter muscle physiology and result in increased susceptibility to the development of metastatic disease at such sites.

Adult↗
PubMed2002

An exploratory study of different types of violence presented in early Christian and Islamic historical documents.

Source documents for Islam and Christianity were analyzed for violent themes. The two religions both condemned criminal violence, and neither supported random violence. Nonviolence was more common in the Christian sources while active violence was much more common in the Islamic documents. Although violence themes are a very small proportion of the content of the documents of either religion, those who seek to justify active violence against perceived enemies may find more support for their actions in early Islamic sources than in early Christian sources. Results are interpreted from a perspective of symbolic interaction.

Bible↗
PubMedDate not supplied

Documenting patient education: a literature review.

Lack of time is cited as the most common reason why staff nurses neglect to document patient education. Consumer rights, standards of practice, and other laws regulating nursing practice require nurses to teach patients. Administration and staff development can enhance nurses' efforts to document more effectively. Forms and flowsheets detailing content and learner outcomes and tracking patients' progress can affect the quality of documentation. Nurses are encouraged to continue developing new forms and flowsheets and to share their products with others.

Forms and Records Control↗
PubMed1989

Do nurses consistently document incontinence?

1. Urinary incontinence is inconsistently documented on medical records of nursing home residents. 2. Documentation of urinary incontinence by professional nurses may be improved by changes in organizational factors such as staffing, policy implementation, and staff education. 3. Forms that employ cue words for eliminative status show more documentation of continence status than forms that have an open format. 4. Evaluation of changes in nursing practice in the nursing home setting can benefit from nursing studies that employ an organizational perspective.

Aged↗
PubMed2006

Informed consent document in gastrointestinal endoscopy: understanding and acceptance by patients.

OBJECTIVE: We wanted to know if patients read and understand the informed consent (IC) document used for endoscopic procedures, and to evaluate the readability of IC. METHOD: During two months we gave patients studied in our endoscopy unit an anonymous questionnaire with different items concerning reading degree, knowledge of the technique, complications, sedation used, and information received. We evaluated IC readability using the Flesch index. RESULTS: 309 patients were included (mean age: 53 years, 55% males, 86% outpatients, 50% with basic education); 85% of patients read the IC, 96% considered they understood the exploration technique, 22% were not aware of severe complications, and 82% knew which kind of sedation would be used; 88% of patients received additional information from their doctors. Outpatients read the IC in a greater percentage versus inpatients (p < 0.05); patients with only basic education tended to ignore the possibility of complications (p < 0.05). Doctors gave more information to rural patients (p = 0.08), offered better information about complications to urban patients (p = 0.09), and offered more information on other diagnostic procedures to patients older than 50 years (p < 0.05). With the Flesch index we found that gastroscopy and colonoscopy ICs had a "standard" level of readability, while ERCP ICs were more complex. CONCLUSIONS: The majority of our patients read and understands the IC. Doctors adapt information to patient characteristics. Our IC documents have an acceptable level of readability, but given that 50% of our patients have only a basic educational status, we should attempt to provide an easier IC document.

Adolescent↗
PubMed1994

Career exploration and development: a companion guide to the Occupational Therapy Roles document.

AOTA has developed OT Roles for practitioners, administrators, educators, researchers, and others to help them appreciate the broad range of opportunities in occupational therapy. This document also helps individuals and groups understand important qualifications for successful performance of key role components. Continuums of typical progression from entry-level to expert are suggested. This companion document demonstrates how OT Roles can be used as a resource for career planning, administration curriculum planning, and the basis for research in the field. Case studies have been presented to show some of the many applications of OT Roles. It is anticipated that through the use of both OT Roles and this companion document, individuals and groups will be able to support continued growth and diversification of the many opportunities within the field of occupational therapy.

Career Mobility↗
PubMed1986

Compulsory admission of the mentally ill: adequacy of documentation.

The issues that are involved in the compulsory detention and treatment of persons with mental illness are complex. There has been an improvement in the adequacy of documentation of such persons in the first five years of operation of the new South Australian Mental Health Act, 1976-1977. However, an appreciable proportion of documents still do not appear to comply adequately with the statutory requirements. This may be related not only to shortcomings in the medical documentation, but also to ambiguities and possible overlapping in the criteria for compulsory detention and treatment.

Australia↗
PubMed1992

Image-based document management systems for medical records.

Using image scanning as a document capture mechanism at time of treatment or on day of discharge automates the medical record to achieve the larger objectives of simultaneous concurrent access to an electronic chart. This form of keyless document capture, although appearing labor intensive, is justified for improving business management and quality of care. Coupled with optical character recognition or barcode recognition for keyless data capture, medical information may be more easily made available for clinical research. Not merely a microfilm alternative, a medical record management system accelerates chart completion. Labor reduction is realized by eliminating filing and retrieval of active charts, loose sheet handling, photocopying, chart assembly, and chart location control. By reducing the reasons for chart completion delays, accelerated billing of Medicare accounts will occur, resulting in a reduction in receivables. Image-based document management systems accomplish the three things required of a senior manager in health care: (1) solve problems, (2) save money, and (3) make money.

Archives↗
PubMed1995

Document imaging vendors and their systems.

As hospital administrators confront the towers of paper generated daily throughout their organizations, document imaging technology promises short-term and possibly long-term relief. Sales of document imaging systems remain strong, probably due to their easy cost justification. The following pages offer an overview, a market sample of document image-vendors who target healthcare.

Catalogs, Commercial as Topic↗
PubMed1995

Electronic documents benefit integrated healthcare networks.

As healthcare entities begin to establish direct links with each other and with sources such as physicians and HMOs, electronic document management plays a key role in facilitating each party's simultaneous access to accurate, real-time data about patients, test results, insurance claims, and many other information levels. Though it may be some time before the majority of healthcare entities are aligned in fully functioning community healthcare integrated networks (CHINs), there is no reason for individual hospitals and healthcare providers to postpone electronic document management. They can realize significant benefits by integrating electronic document management into an organization's information management plan now, and that will help them move into a future CHIN.

Community Health Services↗
PubMed1996

Meeting European and US requirements for design and development documentation, Part I.

Developing design and development procedures and documentation is one of the most important activities in the implementation of a formal design-control programme. Also, companies wishing to comply with the European and the forthcoming United States (US) requirements face a dual challenge. Part I of this series of articles will provide an overview of design control elements and some differences between the European and US requirements. The next two parts will discuss the types of procedures and documentation that are needed to comply with these requirements and a method for organizing documentation to facilitate its use by the company and auditors.

Equipment Design↗
PubMed1997

Interim recommendations for deferral of donors at increased risk for HIV-1 Group O infection; guidance document; availability--FDA. Notice.

The Food and Drug Administration (FDA) is announcing the availability of a guidance document entitled "Interim Recommendations for Deferral of Donors at Increased Risk for HIV-1 Group O Infection," dated December 11, 1996. The guidance document, which discusses the appearance in 1996 of two cases of HIV-1 Group O infection in the United States, is intended to provide interim measures to reduce the risk of HIV-1 Group O transmission by blood and blood products pending the licensure of test kits specifically labeled for detection of antibodies to HIV-1 Group O viruses. The guidance document recommends adding three questions to screening questionnaires used to exclude donors at high risk of HIV-1 infection.

Blood Banks↗