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At least 937 records · Page 52Linked to original sources
PubMed1997

Assessment of asthma using automated and full-text medical records.

Automated medical records systems are used to study clinical outcomes and quality of care, but this requires accurate disease identification and assessment of severity. We sought to determine the reliability of identifying asthmatics through automated medical and pharmacy records, and the adequacy of such data for severity assessment. All adult health maintenance organization (HMO) members who received at least one asthma drug and an asthma diagnosis between April 1988 and September 1991 were identified. Records of a random sample were reviewed to validate the diagnosis and extract clinical information. Asthma drugs were dispensed to 15,491 individuals; 7583 (49%) also received an asthma diagnosis. Asthma drug use was three times greater for persons with diagnosed asthma compared to those with no diagnosis. Record review revealed that a coded asthma diagnosis had a positive predictive value of 86%. Nearly 4000 ambulatory encounters were reviewed, 10% of which were for asthma; the median number of encounters was two. Asthma symptoms were mentioned in 9% of all encounters; wheezing was most common. Peak flow and spirometry were measured in 4% and 1% of encounters, respectively. Records from recipients of asthma drugs who lacked an asthma diagnosis showed that 79% did not have asthma. Automated medical and pharmacy records from an HMO were relatively accurate when used to identify individuals with asthma. Similarly, most asthma drug recipients who lacked a coded diagnosis of asthma did not have asthma. However, conventional full-text records usually do not contain sufficient information to assess asthma severity, limiting the utility of such records for research and quality improvement.

Adult↗
PubMed1983

Use of later records in dairy sire evaluation: a review.

Performance in first lactation has been the standard of evaluation for most genetic studies with dairy cattle. First records are available sooner on more cows and are less susceptible to error from selection, injury, previous days dry, and mastitis than are later records. However, first records have been considerably less than perfect in predicting traits of lifetime performance, which should be the primary selection objective in dairy cattle. Later records provide additional information for more accurate sire evaluations and should be a better index of health and resistance to mastitis than first lactations. The economic importance of later records relative to first is that there are more and actual yields are higher. Herds with more older cows can reduce commitment of resources to heifer rearing, and heifers can be selected more intensely prior to first calving than herds with more cows of younger ages. Some sire evaluation systems ignore later records because of computational expense, potential selection bias, and difficulty of age adjustment. Later records may contain useful information relative to lifetime profitability of sire progeny groups. Development of proper methodology for utilizing information available in later records appears fruitful for research.

Animals↗
PubMed1993

The introduction of computer-based patient records in The Netherlands.

Computer-based patient records, although an area of active research, are not in widespread use. In June 1992, 38% of Dutch general practitioners had introduced computer-based patient records. Of these, 70% had replaced the paper patient record with a computer-based record to retrieve and record clinical data during consultations. Possible reasons for the use of computer-based patient records include the nature of Dutch general practice and the early and active role of professional organizations in recognizing the potential of computer-stored patient records. Professional organizations issued guidelines for information systems in general practice, evaluated available systems, and provided postgraduate training that prepares physicians to use the systems. In addition, professional organizations successfully urged the government to reimburse general practitioners part of the expenses related to the introduction of computer-based patient records. Our experience indicates that physicians are willing and able to integrate information technology in their practices and that professional organizations can play an active role in the introduction of information technology.

Database Management Systems↗
PubMed1987

Altered medication orders in medical records.

A 1-month study was conducted at a teaching hospital to determine how often medication orders in a medical record are improperly altered after orders have been written. This was determined by comparing the pharmacy copy of the physician order, which is removed from the medical record as the orders are written, with the medical record after the patient has been discharged. Five percent of the discharged patients whose records were examined had a record which had been improperly changed. This was ascertained by examining 1,125 individual medication orders, of which 4 were found to be altered. The altered records are shown. A policy statement is presented on how to properly correct an entry in a medical record. Inservice training and adequate orientation must be provided for all those who make entries in the medical record.

Documentation↗
PubMed1999

Self-assessment of the forensic value of dental records.

One of the most important aspects of a person's dental record may well prove to be it's potential value should the forensic dental identification of their remains become necessary. The better the quality of the antemortem dental records, the easier and faster the identification of the remains will be. The forensic dentist must be able to select identifying features by decoding the deceased's antemortem dental records. A study was conducted on two groups of dentists who were asked to self-assess the forensic dental value of the dental records maintained in their own practices. The three most frequently recorded identifying dental features, other than caries and restorations, were the presence of diastemas, displaced or rotated teeth, and dental anomalies. Surveyed dentists imbedded identifying information into the removable prosthetic devices fabricated for their patients an average of only 64% of the time. Only 56% of the two groups combined felt that their dental chartings and written records would be extremely useful in dental identifications. It is concluded that the quality of antemortem dental records available for comparison to postmortem remains varies from inadequate to extremely useful. Practicing dentists can become valuable members of the dental identification process by developing and maintaining standards of record keeping which would be valuable in restoring their patients' identity.

Adult↗
PubMed1999

A record-retention program can protect group practices.

Group practices can benefit from having a systematic record-retention program that includes a formal record-retention policy. While state and Federal laws require the retention of some types of business records, many other records should be retained in the event of an audit or litigation. Having a record-retention program in place can help group practices respond cost-effectively and efficiently when called upon to produce documentation. The record-retention program should include a policy that stipulates not only which records should be kept but also for how long. Group practices should retain records relating to patient care, taxes, payroll, and contracts.

Cost-Benefit Analysis↗
PubMed2000

How accurately does the medical record capture maternal history of cancer?

We sought to assess the reliability of information regarding the maternal history of cancer by comparing the medical records of 214 women with breast cancer, ages 26-59 years and diagnosed in 1974-1995, and of their controls with the medical records of their mothers. Subjects were members of Kaiser Permanente, Northern California, selected for a study of early-life predictors of breast cancer. For any type of cancer identified in the mother's medical record, the proportion noted in the daughter's medical record at least 6 months before the daughter's diagnosis or reference date was 56% among cases and 32% among controls. The odds ratio for the association of maternal cancer history with breast cancer risk was 2.1 using the maternal record and 3.5 using the subject's record. For a maternal history of breast cancer, the proportion noted in the subject's record was 79% among cases and 57% among controls, and the odds ratios were 4.0 and 6.5, respectively. We believe that the case-control difference in missing information was attributable to higher utilization of breast cancer screening among cases. This study illustrates the need to assess the impact of screening differences on the ascertainment of information from the medical records.

Adult↗
PubMed2002

Closing the loop between clinical practice, research, and education: the potential of electronic patient records.

OBJECTIVE: To discuss the possible contribution of electronic patient records in closing the loop among clinical practice, research and education. RESULTS AND CONCLUSIONS: Applying Information and Communication Technology (ICT) to a given medical domain is not merely adding a new technique. When introduced into an environment, ICT will initially often emulate or resemble the already existing processes. When workers and researchers in that domain begin to appreciate the potential of ICT, this initial stage is followed by more fundamental changes in that domain that take advantage of the potential of ICT. To understand the scope of the potential changes enabled by electronic records, three principle changes need to be understood. First, data recorded in computer memories can be readily retrieved and re-used for a variety of purposes. Second, once data are available in computer memories, the data can be transported easily. Third, as physicians (and patients) are using computers to record medical data, the same electronic record can be used to introduce other computer programs that interact with the user. New usage of data, however, generates additional requirements. Thus the experience in developing decision support systems and analyzing observational databases feeds back into the requirements for electronic medical records. Each patient-physician encounter, each investigation, each laboratory test, and each treatment in medical practice constitutes, in principle, an experiment. Ideally, we learn from each experiment. Electronic medical records will facilitate research that relies on data recorded in routine medical practice. The potential and challenge, however, of Medical Informatics lies in its ability to close the loop among clinical practice, research, and education.

Databases, Factual↗
PubMed1999

Linking Community Health Index and Scottish Morbidity Records for neonates: the Grampian experience.

OBJECTIVE: To describe linking Community Health Index (CHI) records with Scottish Morbidity Records for neonates (SMR11) for the purpose of follow-up in a large clinical trial. DESIGN: A two-stage probabilistic computer match based on date of birth, surname and postcode, supplemented with hand matching. SETTING: Aberdeen Maternity Hospital, Grampian. SUBJECTS: 10,835 babies born in the two year period between 1 March 1993 and 28 February 1995. RESULTS: The computerised linkage matched 89.8% of the SMR11 records to a CHI record. All of the remaining 10.2% unlinked babies were accounted for by manual checking. There were 194 (1.8%) babies who did not have a CHI record due to the baby leaving the area or dying before allocation was possible. The sensitivity of the matching was estimated at 99.9% (95% CI is 99.8% to 100%). CONCLUSION: We were able to correctly computer match 89.7% of our babies' SMR11 records with the appropriate CHI number. We have shown that the follow-up of neonates in a clinical trial setting using record linkage between secondary and primary care systems is feasible, efficient and useful. However, this exercise would have been greatly facilitated by a unique NHS identifier common to all records.

Clinical Trials as Topic↗
PubMedDate not supplied

Evaluation of vertical accuracy of interocclusal records.

PURPOSE: The aim of this study was to evaluate four recording materials (polyether, polyvinyl siloxane, acrylic resin, and wax) for their ability to accurately record, maintain, and reproduce the vertical interocclusal relationship. MATERIALS AND METHODS: A metallic apparatus was used to represent the opposing arches; its epoxy resin duplicate represented the working casts. The vertical discrepancies produced because of the presence of the records were measured both after repositioning them on the metal apparatus and after transferring them onto the casts. Two-way ANOVA was performed. RESULTS: Closure through the interocclusal recording materials produced small vertical discrepancies ranging from 24 to 74 microm. When repositioned on the apparatus, the vertical discrepancies were greater. The lowest discrepancy was displayed by polyvinyl siloxane (101 microm) and polyether (107 microm), and the greatest was displayed by wax (168 microm). When records were transferred onto casts, the discrepancies were approximately 0.5 mm, without significant differences among materials. CONCLUSION: Closure through interocclusal recording materials and removal and repositioning of the records on the apparatus produced small vertical discrepancies with clinically insignificant differences between the materials tested. When records of all materials tested were transferred onto casts, vertical discrepancies of approximately 0.5 mm were found, which is of clinical concern.

Acrylic Resins↗
PubMed2006

A project to improve the computerization procedure of emergency nursing record.

This project is to implement the computerization procedure of emergency nursing record. The nursing record must be complete and correct enough to present the uniqueness of different specialty. We encouraged nurses to participate in classroom lessons of informatics technology in nursing records. We then used the standardized version of the emergency nursing records. We also set up criteria for computerization of nursing records. As a result, the nursing records become more complete. It was improved by 8.5% as compared to manual records. The satisfaction of nurses was improved by 82.1%. It is much more time-saving and convenient to check the nursing records. In conclusion, the emergency nursing profession and quality surveillance did improve from the computerization. The patients will receive better nursing care quality.

Consumer Behavior↗
PubMed1991

The sensitivity of medical diagnostic decision-support knowledge bases in delineating appropriate terms to document in the medical record.

A pertinent, legible and complete medical record facilitates good patient care. The recording of the symptoms, signs and lab findings which are relevant to a patient's condition contributes importantly to the medical record. The consideration and documentation of other disease states known to be related to the patient's primary illness provide further enhancement. We propose that developing sets of disease-specific core elements which a physician may want to document in the medical record can have many benefits. We hypothesize that for a given disease, terms with high importance (TI) and frequency (TF) in the DX-plain, QMR and Iliad knowledge bases (KBs) are terms which are used commonly in the medical record, and may be, in fact, terms which physicians would find useful to document. A study was undertaken to validate ten such sets of disease-specific core elements. For each of ten prevalent diseases, high TI and TF terms from the three KBs mentioned were pooled to derive the set of core elements. For each disease, all patient records (range 385 to 16,972) from a computerized ambulatory medical record database were searched to document the actual use by physicians of each of these core elements. A significant percentage (range 50 to 86%) of each set of core elements was confirmed as being used by the physicians. In addition, all medical concepts from a selection of full text records were identified, and an average of 65% of the concepts were found to be core elements.(ABSTRACT TRUNCATED AT 250 WORDS)

Artificial Intelligence↗
PubMed1990

General practitioners' knowledge about patients and use of medical records in out of hours calls.

The medical record is an established adjunct to good care and this paper describes the extent to which general practitioners use patients' records in out of hours calls and how their previous knowledge of their patients affects the decision to visit. Seven general practitioners from three group practices in Cambridge and Newmarket each operating a separate out of hours rota recorded details of out of hours telephone calls. Of 368 calls recorded, 293 (80%) resulted in a visit. In 51% of calls the patient was known to the doctor but the doctors were just as likely to visit patients they knew as those unknown to them. In 41% of the calls the doctors were able to recall a degree of clinically relevant information about the patient. In 47 of the calls (13%) recalled information concerning the patient was an influence in the decision whether to visit. The patient's record was collected before the visit in 30% of visits to the elderly compared with 17% for all age groups. The most often quoted reasons for not collecting the medical record were that it was likely to be unhelpful and/or it was geographically inconvenient. Although doctors who collected the record found it useful in 84% of cases, obtaining the record either before or after the visit rarely changed the management of the patient. On the occasions when it did affect management it was of importance both clinically and medico-legally.(ABSTRACT TRUNCATED AT 250 WORDS)

England↗
PubMed1990

Does awareness of being video recorded affect doctors' consultation behaviour?

Four general practitioners, two of whom had no previous experience of video recording in the consultation, took part in a study to assess the effect of awareness of video recording on their consultation behaviour. A video camera was sited unobtrusively in each consulting room for a month during which five randomly selected surgeries were recorded with the doctors being informed at the time, and five without their being informed. The video recorded consultations were analysed using TIMER, a tool designed to measure objectively behaviour in terms of physical, verbal and secondary activities in consultations. The proportions of time spent on the 27 consultation parameters were compared when doctors were aware and unaware of the recording, using analysis of variance. This demonstrated only one significant difference, in the low frequency parameter of the doctor's exploration of the patients' concepts (P less than 0.05). In a secondary analysis of the first four consultations in each surgery, where any effect of the presence of the video camera would be expected to be most marked, there was again only one significant difference in the 27 parameters (in patient preparation; P = 0.01). No significant difference owing to awareness of video recording was found in consultation length, the number of problems dealt with, or previous inexperience of video recording. When surgeries at the start of the month were compared with those at the end, four significant differences (P less than 0.05) out of 108 areas were demonstrated both when the doctor was aware and unaware of video recording, and there was no consistency in the direction of the differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Awareness↗
PubMed1990

Should the complete medical record be computerized in family practice? An opposing view.

The goal of replacing the entire paper chart with an electronic record may be a subtle barrier to the spread of computer-stored medical records. The focus on needing to replace the current paper chart draws attention away from the benefits of having parts of the record stored in a computer retrieval form. Furthermore, the focus on total computerization implies a large initial and ongoing dollar commitment to replace the record completely. This commitment is unacceptable to most practices. No doubt, there are advantages of computerizing key patient data. Only key data should be computerized, however, not all data. Patient summaries containing the patient's demographics, medical problems, allergies, health maintenance status, and recent laboratory results can be used to generate needed prevention reminders as well as to do research (such as postmarketing drug surveillance) and management (such as being able to compare the utilization of various laboratory tests by physicians). Computer searches of these data can also be used to create patient target groups and to produce individualized labels and letters to contact patients. The computer medical record should complement, not replace, the traditional office record. The computer then can be used for a subset of the full record to take advantage of its unique power of retrieval and analysis. As a supplement to the record, the computer can be implemented in a modular step-by-step fashion rather than all at once with its attendant costs. This approach implies that the goal is more effective care of patients rather than a fascination with high technology.

Ambulatory Care Information Systems↗
PubMedDate not supplied

The patient's periodontal record. Its legal implications.

Records are the backbone of the dentist's defense in any malpractice claim. Cases involving periodontal disease--failure to timely diagnose, failure to adequately treat, and failure to refer--are responsible for a great number of lawsuits against dentists. Since individuals of all ages are susceptible to periodontal disease, all dental records should contain periodontal evaluations data. This article discusses what information should be recorded in order to assist any attorney defending the dentist or, in many instances, how the completeness of such information may deter a plaintiff's attorney from proceeding with a suit. The information recorded should enable the dentist to assess the patient's health, assess the patient's dental status, diagnose any existing periodontal disease, and provide a diagnosis and treatment plan for the patient. In addition, the record must reflect the consent of the patient to the eventual treatment, the progress notes made during treatment, and completion notes at treatment's end. Finally, the dentist must be made aware of the legality of terminating the doctor/patient relationship and the transfer of records. Complete and accurate records can substantiate proper diagnosis and treatment and/or contributor negligence but poor records may be insufficient to protect even an innocent dentist.

Adult↗
PubMed1990

Medical examiner/coroner records: uses and limitations in occupational injury epidemiologic research.

Epidemiologic research often relies on existing data, collected for nonepidemiologic reasons, to support studies. Data are obtained from hospital records, police reports, labor reports, death certificates, or other sources. Medical examiner/coroner records are, however, not often used in epidemiologic studies. The National Institute for Occupational Safety and Health's Division of Safety Research has begun using these records in its research program on work-related trauma. Because medical examiners and coroners have the legal authority and responsibility to investigate all externally caused deaths, these records can be used in surveillance of these deaths. Another use of these records is to validate cases identified by other case ascertainment methods, such as death certificates. Using medical examiner/coroner records also allows rapid identification of work-related deaths without waiting several years for mortality data from state offices of vital statistics. Finally, the records are an invaluable data source since they contain detailed information on the nature of the injury, external cause of death, and results of toxicologic testing, which is often not available from other sources. This paper illustrates some of the ways that medical examiner/coroner records are a valuable source of information for epidemiologic studies and makes recommendations to improve their usefulness.

Accidents, Occupational↗
PubMedDate not supplied

[Evaluation of alcohol consumption recording in the primary care clinical history].

We carried out an internal medical audit to evaluate the recording of alcohol use in the primary care clinical records. 200 records were analyzed out of overall 2250. Of these, 100 belonged to the open (older) model, and 100 to the closed (or current) one. We found that in 56% of open model records there was no mention about alcohol use, against 31% in closed model records. In addition, this latter model permits a quantitative recording of alcohol intake. In both models there was a greater amount of information in males. We conclude that the physician's interest in recording data related to alcohol intake is small. We think that primary care staff should be sensitized to the importance of evaluating and recording alcohol intake.

Adult↗