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At least 955 records · Page 53Linked to original sources
PubMed1989

[Access to psychiatric and child psychiatric case records in the Copenhagen County Hospital in Nordvang in 1987].

Commencing on 1.1.1987, all requests for access to case records were registered prospectively in all of the Copenhagen County Hospitals. In the Copenhagen County Hospital, Nordvang, 103 requests were made for access to the case records in the course of 1987. Ninety-five requests in the adult departments resulted in complete access in 90 cases, limited access in one case while access was refused in three cases. One person making the request did not turn up. Eight requests concerning patients in the child psychiatric department resulted in complete access in one case, limited access in five cases while access was refused in two cases. This corresponds to 3.0% in the departments for child psychiatry and 2.7% in the departments for adults. No deterioration in health was observed in any of the 97 cases where access was permitted. In many cases, insight into the case records may, on the other hand, be a good therapeutic measure. On two cases only, access to the case records was given to a third person with the patient's permission, and the majority of the patients did not request a copy of the case records but accepted access to the case records in the form of the right to read the case records with assistance, if necessary. It is concluded that in the first year after introduction of the Danish legislation concerning access to the case records, this ran very smoothly with fewer difficulties than anticipated in a large psychiatric hospital in the region of the capital.

Child↗
PubMed1988

Legal requirement of private practice medical records.

The hospital medical record is a critical communication vehicle for the numerous health professionals who provide care to each patient. It is also an essential evidentiary tool in malpractice suits. Even though the medical record is not the sole information upon which the courts will rely in determining negligence liability, it can serve as an important chronology of care. Dietitians entering private practice, whether with a physician or not, should establish a system of record keeping. Although specific standards have not been set for private patient records, it is argued that records kept must meet many of the requisite guidelines for medical records in institutional settings. Additionally, the records must provide documentation that may be absent and difficult to obtain in the private setting. Discussed are legal issues surrounding patient records of the dietitian in private practice.

Defensive Medicine↗
PubMed1978

Arrhythmias in ambulatory persons. A review and experience of 1,000 consecutive recordings.

The value of 24-hour ambulatory monitoring of the ECG for the diagnosis of symptoms of dizziness, palpitations and syncope is controversial. In this study results from a hospital-based, clinical service have been analysed. Of 1,000 consecutive dynamic electrocardiograms (DCG), 678 were performed for assessment of dizziness, syncope or palpitations in 405 patients. 36 of the patients had pacemakers. 60 DCGs were technically inadequate. The recordings were classified according to the correspondence between DCG findings and symptoms noted in the patient diary: (I) Completely diagnostic: significant arrhythmias (SA) corresponding to diary symptoms - 99 recordings. (II) Incompletely diagnostic: (a) absence of SA in the presence of diary symptoms - 90 recordings; (b) presence of SA but no diary symptoms - 197 recordings; (c) presence of SA corresponding to symptoms other than that for which the DCG was indicated - 52 recordings. (III) Non-diagnostic: absence of both SA and diary symptoms - 180 recordings. Incompletely diagnostic categories were regarded as clinically valuable in that they either excluded a cardiac arrhythmia as a cause of symptoms (group IIa) or they revealed SA which did not correspond to diary symptoms (group IIc). The absence of symptoms corresponding to SA was ascribed to poor diary keeping in 54 of 197 recordings. These results are discussed in the context of the findings in normal and symptomatic patients. A clinical 24-hour ambulatory ECG monitoring service provided useful diagnostic information in 65% of recordings and 74% of patients.

Adolescent↗
PubMed1993

An evaluation of the personal child health record in Fife.

Personal child health records were introduced in Fife in March 1992; an evaluation carried out in November 1992-February 1993 sought the views of both parents and health professionals and examined a sample of the records. All 104 parents who were interviewed considered it important that they hold a copy of their child's health record. The majority made good use of the personal child health record by bringing it regularly to clinics and by reading or completing the appropriate sections. The views of health professionals were mixed and some specific problems were raised. However, there is still relatively limited experience with the record in Fife; it is possible that professional endorsement of it will grow with increasing experience in its use. Suggestions for improvements should be acted upon where possible to encourage regular and correct use. The loose leaf format of the record facilitates the incorporation of amendments. The use of the record in Fife should be promoted by emphasising that, despite individual views of health professionals about the record, the great majority of parents value it and the improved access to the information about their child's health which it represents.

Adult↗
PubMed1995

Two methods of authenticating past criminal conduct by psychiatric inpatients: a comparison of clinical chart reports and criminal records.

Clinical chart reports on criminal activity based primarily on the patients' own reports were compared with official criminal records of their convictions in a large group of male inpatients suffering from schizophrenia, affective disorder and alcoholism. In 69% of the cases studied there was uniformity between both methods of ascertaining criminal activity. A considerable proportion (26%) of schizophrenic patients' clinical charts indicated criminal behaviour which was not officially registered in criminal records, whereas a substantial proportion (24%) of alcoholics did not report their criminal activities in their clinical records in spite of these being recorded in their criminal records. The conclusion is that official criminal records provide an incomplete account of infractions of the law by psychiatric, especially schizophrenic patients. The information recorded in official records seems to be less accurate than that in clinical charts in the case of schizophrenics, but more veracious in the case of alcoholics. When investigating the frequency of criminal behaviour by psychiatric patients these findings will therefore have to be taken into consideration.

Adult↗
PubMed1995

The electronic patient record: a strategic planning framework.

Sunnybrook Health Science Center (Sunnybrook) is a multifacility academic teaching center. In May 1994, Sunnybrook struck an electronic patient record taskforce to develop a strategic plan for the implementation of a comprehensive, facility wide electronic patient record (EPR). The taskforce sought to create a conceptual framework which provides context and integrates decision-making related to the comprehensive electronic patient record. The EPR is very much broader in scope than the traditional paper-based record. It is not restricted to simply reporting individual patient data. By the Institute of Medicine's definition, the electronic patient record resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge, and other aids [1]. It is a comprehensive resource for patient care. The taskforce proposed a three domain model for determining how the EPR affects Sunnybrook. The EPR enables Sunnybrook to have a high performance team structure (domain 1), to function as an integrated organization (domain 2), and to reach out and develop new relationships with external organizations to become an extended enterprise (domain 3) [2]. Domain 1: Sunnybrook's high performance teams or patient service units' (PSUs) are decentralized, autonomous operating units that provide care to patients grouped by 'like' diagnosis and resource needs. The EPR must provide functions and applications which promote patient focused care, such as cross functional charting and care maps, group scheduling, clinical email, and a range of enabling technologies for multiskilled workers. Domain 2: In the integrated organization domain, the EPR should facilitate closer linkages between the arrangement of PSUs into clinical teams and with other facilities within the center in order to provide a longitudinal record that covers a continuum of care. Domain 3: In the inter-enterprise domain, the EPR must allow for patient information to be exchanged with external providers including referring doctors, laboratories, and other hospitals via community health information networks (CHINs). Sunnybrook will prioritize the development of first domain functionality within the corporate constraints imposed by the integrated organization domain. Inter-enterprise computing will be less of a priority until Sunnybrook has developed a critical mass of the electronic patient record internally. The three domain description is a useful model for describing the relationship between the electronic patient record enabling technologies and the Sunnybrook organizational structures. The taskforce has used this model to determine EPR development guidelines and implementation priorities.

Medical Records Systems, Computerized↗
PubMed1996

A positive, systematic approach to improve inpatient medical record completion in a family practice residency program.

BACKGROUND AND OBJECTIVES: Timely completion of medical records is a concern for many reasons. For physicians, incomplete records may result in loss of hospital privileges and income and increased legal liability after entering practice. Traditionally, medical record delinquencies have been dealt with punitively. We developed a multifaceted approach to inpatient medical record completion and implemented it at our hospital. METHODS: The intervention involved posting weekly lists of physicians who were in compliance or noncompliance with medical records completion requirements, giving positive rewards (candy bars) for those who were in compliance, and increasing faculty contact with residents over issues of medical records completion. RESULTS: This approach reversed an increasing hospital record delinquency rate that had exceeded 50% and reduced the rate to 10%-30%. Residents' views of the various components of the intervention were positive. CONCLUSION: Medical records completion rates can be increased with positive, rather than punitive, measures.

Data Collection↗
PubMed1997

Assessing case records using monitor criteria developed from consensus guidelines.

OBJECTIVE: To develop criteria to enable the monitoring of general practitioner (GP) case records using consensus guidelines for conditions commonly managed in general practice and to measure how well the case records of a non random sample of GPs conformed to these criteria. METHOD: An iterative process was used to develop criteria from consensus guidelines for 19 conditions. Criteria were also developed to enable monitoring of the structure and content of the patient case record. A non random sample of GPs in Adelaide was approached to allow measurement of the content of their case records against these criteria. This measurement was undertaken by allied health professionals. An overall percentage score of conformity with the criteria was created for 10 acute, and six chronic conditions and for the patient case record review. These were rank ordered and Kendall's rank order correlation coefficients were used to compare the results in these three areas of practice. RESULTS: Criteria were successfully developed for each condition. Thirty-one GPs had their patient case records assessed. There was substantial variability between these practitioners in their conformity to the criteria. Kendall's rank order coefficients found statistically significant correlation between the results for acute and chronic conditions, and between acute conditions and the patient case record review section. CONCLUSION: It is feasible to develop criteria that enable measurement of the conformity of GP case records to these criteria. The overall level of conformity, together with the substantial variability found between practitioners suggest that there is a need for GPs to address this area of their practice.

Clinical Competence↗
PubMed1997

High performance seizure-monitoring system using a vibration sensor and videotape recording: behavioral analysis of genetically epileptic rats.

A new seizure-monitoring apparatus containing a piezoceramic vibration sensor combined with videotape recording was developed. Behavioral analysis of Ihara's genetically epileptic rat (IGER), which is a recently developed novel mutant with spontaneously limbic-like seizures, was performed using this new device. Twenty 8-month-old male IGERs were monitored continuously for 72 h. Abnormal behaviors were detected by use of a vibration recorder, and epileptic seizures were confirmed by videotape recordings taken synchronously with vibration recording. Representative forms of seizures were generalized convulsions and circling seizures. Generalized convulsions were found in 13 rats, and circling seizures in 7 of 20 animals. Two rats had generalized and circling seizures, and two rats did not have seizures. Although there was no apparent circadian rhythm to the generalized seizures, circling seizures occurred mostly between 1800 and 0800 h. A correlation between the sleep-wake cycle and the occurrence of circling seizures seems likely. Without exception, all the seizure actions were recorded by the vibration recorder and the videotape recorder. To eliminate the risk of a false-negative result, investigators scrutinized the information obtained from the vibration sensor and the videotape recorder. The newly developed seizure-monitoring system was found to facilitate detailed analysis of epileptic seizures in rats.

Animals↗
PubMedDate not supplied

How to manage hospital records.

It has been documented that hospitals with records retention programs have 55 percent less records, spend less time on record maintenance and retrieval of records and can find records on demand when requested. This all adds up to savings in time and space and improved quality in an age when these commodities are precious resources. No other industry that I can think of has as its mainstay the need for good quality records as hospitals do. Don't pass up this opportunity to manage your records as carefully as you have been managing your other resources: money, manpower and materiel.

Hospital Departments↗
PubMed1977

What happens when hospitalized patients see their own records.

The effect of giving hospitalized medical patients access to their problem-oriented hospital records was investigated. Twenty-five subjects were given free access to their records while 25 other subjects served as controls. Few of the open record group actively sought and studied their records; most elected to see them only as part of routine ward rounds; and one objected to seeing the record at all. Taking the experimental group as a whole, there was no measurable effect of seeing the record on the subjects' ability to list their diagnoses or medications, their self-assessment of depression, anxiety or contentment, or their attitudes toward selected components of the health care system. On the other hand, in individual instances access to the hospital record seemed to facilitate communication and provide an opportunity for hospital inpatients to monitor objectively their hospital course.

Australia↗
PubMed1991

Health record completion guidelines. American Health Information Management Association.

It is a pleasure to introduce this important project report to the American Health Information Management Association (AHIMA) membership. Analyzing records for omissions, notifying physicians of needed information, counting delinquent records, and pursuing late documentation are some of the biggest chores in today's health information management departments. And they are chores that take time away from other priorities--managing, analyzing, and presenting health data, planning and implementing computerization, assessing and meeting customer needs. The heart of this statement is simple: it points out that there are other options to the traditional, detailed, record-by-record analysis. And those options may give us the results we need--timely and complete health records--while freeing up valuable staff time for other priorities. Take a serious look at the statement. If you are eager to make a change in your department's practices in records analysis and completion, it will back you up. If you are comparing the value of your department's records completion work to its benefit, this statement will give you ideas for change. And if you don't think you'd ever challenge tradition, this statement will give you food for thought. An added value to this statement is the fact that the ideas in it, and the very statement itself, are the product of our own profession. We are fortunate that leading-edge practitioners gave their expertise to the entire profession. The members of the strategy group for this project are listed above, we thank them for their wisdom.

Communication↗
PubMed1999

Attitudes towards, and utility of, an integrated medical-dental patient-held record in primary care.

BACKGROUND: The need for closer coordination between primary care medical and dental services has been recognized. AIM: To assess the attitudes of general medical practitioners (GMPs), general dental practitioners (GDPs), and patients to an integrated medical-dental patient-held record (integrated medical-dental PHR); to examine patients' use of these records, and the utility of the records for doctors and dentists. METHOD: A three-phase study was carried out: (1) postal survey of GMPs and GDPs; (2) randomized trial of patients, using postal questionnaires before and one year after the issue of integrated medical-dental PHRs to cases; (3) assessment by doctors and dentists of anonymized integrated medical-dental PHRs from this trial. The study was carried out in medical and dental practices in affluent and deprived areas in Greater Glasgow Health Board. Two hundred and thirteen GMPs, 183 GDPs, and 369 patients registered with GMPs and GDPs were surveyed. Eighteen GDPs and GMPs assessed the integrated medical-dental PHRs. RESULTS: Eighty per cent of dentists had contacted a doctor and 16% of doctors had contacted a dentist in the previous three months; 87% of dentists and 68% of doctors thought an integrated medical-dental PHR would be of some use. Twenty-one per cent of dentists and 85% of doctors had practice computers. Most patients wanted to be able to see and read their own records. Twenty-four per cent of patients said there were mistakes and 30% noticed omissions in the integrated medical-dental PHR issued. Experience of having an integrated medical-dental PHR made patients more positive towards the idea of having a patient-held record and being able to check the accuracy of records. Integrated medical-dental PHRs contained important information for half the GDPs and one-third of the GMPs. CONCLUSION: Both professionals and patients have reasonably positive attitudes towards the use of patient-held records. Among patients, the experience of having the integrated medical-dental PHR led to greater enthusiasm towards the idea. Dentists in particular would benefit from the transfer of information from doctors, but better methods are needed to ensure that patients take the integrated medical-dental PHR with them. Given the current lack of ability to easily produce an integrated medical-dental PHR, further examination of the routine issue of a copy of their medical summary, by GMPs, to all patients would be worthwhile.

Attitude of Health Personnel↗
PubMed2000

A method for removing imaging artifact from continuous EEG recorded during functional MRI.

Combined EEG/fMRI recording has been used to localize the generators of EEG events and to identify subject state in cognitive studies and is of increasing interest. However, the large EEG artifacts induced during fMRI have precluded simultaneous EEG and fMRI recording, restricting study design. Removing this artifact is difficult, as it normally exceeds EEG significantly and contains components in the EEG frequency range. We have developed a recording system and an artifact reduction method that reduce this artifact effectively. The recording system has large dynamic range to capture both low-amplitude EEG and large imaging artifact without distortion (resolution 2 microV, range 33.3 mV), 5-kHz sampling, and low-pass filtering prior to the main gain stage. Imaging artifact is reduced by subtracting an averaged artifact waveform, followed by adaptive noise cancellation to reduce any residual artifact. This method was validated in recordings from five subjects using periodic and continuous fMRI sequences. Spectral analysis revealed differences of only 10 to 18% between EEG recorded in the scanner without fMRI and the corrected EEG. Ninety-nine percent of spike waves (median 74 microV) added to the recordings were identified in the corrected EEG compared to 12% in the uncorrected EEG. The median noise after artifact reduction was 8 microV. All these measures indicate that most of the artifact was removed, with minimal EEG distortion. Using this recording system and artifact reduction method, we have demonstrated that simultaneous EEG/fMRI studies are for the first time possible, extending the scope of EEG/fMRI studies considerably.

Adult↗
PubMed1990

Results with multichannel topographical bipolar recordings of the visual evoked potential in normals and amblyopes.

The method currently used to record topographical voltage distributions of visual evoked potentials is that of monopolar recording with respect to some arbitrary reference electrode. As an alternative we investigated the method of bipolar topographical recording of the checkerboard reversal evoked potential in four amblyopic patients and ten normal persons. The recordings were performed with a system of 14 bipolar channels, arranged in a rectangular grid with an interelectrode distance of 15% of the inion-nasion distance and centered 3 cm above the inion. The gradient distributions of the visual evoked potential obtained from normal persons showed at the time of component P2 a maximum about 3 cm above the inion. The healthy eyes of the amblyopic patients showed similar distributions and latencies. The amblyopic eyes showed normal or reduced amplitudes and normal or increased latencies with large checks and low amplitudes with smaller checks. The topographical distributions recorded with the bipolar recording system showed shifts of the maxima with the larger patterns in three of four amblyopic eyes. A technical comparison showed that these shifts can be recorded by the bipolar recording method with higher accuracy than with the monopolar method, promising a better understanding and more accurate diagnosis of amblyopia.

Adult↗
PubMed1988

Influence of recording techniques on measurement of canine colonic motility.

The extent to which the established variability in colonic motility recordings is due to differences in recording techniques is not known. The aim of this study was to compare the ability of two intraluminal recording devices (perfused tube and tube mounted strain gauge) to record colonic motor activity against a reference device (serosal strain gauge). In six anesthetized dogs an intracolonic probe was positioned such that the component perfused tubes and tube mounted strain gauges were approximated to identical strain gauges mounted on the serosa. Contractions were induced by field stimulation and intraarterial injections of acetylcholine and carbachol. While both intraluminal devices demonstrated limitations in the detection of phasic and tonic motor events, perfused tubes detected a significantly greater proportion of tonic and phasic contractions than did strain gauges (P less than 0.001). Intraluminal strain gauges misrepresented 50% of tonic contractions (confirmed visually and by serosal strain gauges) as waveforms with negative polarity. This was not seen in recordings from perfused tubes. Perfused tubes represented tonic contractions as biphasic or bifid waveforms significantly less frequently than strain gauges (P less than 0.05). Radial asymmetry of colonic contractions is likely to account for these observed discrepancies. Recorded motility patterns are influenced by different recording techniques, and these differences are a source of variability in recorded patterns of colonic motor activity.

Acetylcholine↗
PubMedDate not supplied

The c-wave of the electroretinogram recorded under clinical conditions from rabbits.

To determine whether large and repeatable c-waves can be recorded from rabbits with equipment already in use in clinical electroretinographic laboratories, the Burian-Allen electrode, connected bipolarly or monopolarly, was used to record electroretinograms from pigmented rabbits. The Jet electrode was also used. The c-waves elicited by long-duration (4-second) stimuli were compared to those elicited by stroboscopic stimuli. In addition, the c-waves recorded with direct-coupled amplification were compared to those recorded with condenser-coupled amplification (one-half-amplitude bandpass=0.1 Hz). The b-wave amplitude was not altered by the amplifier coupling or by the two stimulus durations. The largest c-waves were elicited by 4-second-duration stimuli and recorded with direct-coupled amplification. Although the c-wave amplitude was reduced by stroboscopic stimuli and by condenser coupling, large and repeatable c-waves were elicited by stroboscopic stimuli and recorded with condenser-coupled amplification. A comparison of stimulus duration and amplifier coupling showed that the stimulus duration was more important in recording large-amplitude c-waves. Similar results were obtained with the Jet electrode. We conclude that repeatable and large c-waves can be elicited by a stroboscopic stimuli and can be recorded with condenser-coupled amplification with good low-frequency response from rabbits.

Animals↗
PubMed2002

Neurophysiological evaluation of the corticospinal tract by D-wave recordings in young children.

OBJECTIVE: The objective was to neurophysiologically evaluate corticospinal tract (CT) maturation in children younger than 36 months by recording D-waves. METHODS: In 19 children, D-wave recordings were attempted during resection of intramedullary spinal cord tumors (imSCTs). D-waves were elicited by transcranial electrical stimulation (TES; single pulse, anodal stimulation) and recorded from a catheter-electrode inserted into the epidural space caudal to the imSCTs. The presence of the D-wave was analyzed in respect of the patients' age. RESULTS: A D-wave was present in 7 children (21-36 months) and absent in the remaining 12 children (8-31 months). In the youngest child (21 months) the D-wave was recorded from the lower thoracic spinal cord. CONCLUSION: These D-wave recordings indicate that in the immature CT a synchronized descending volley via fast conducting fibers is evoked by TES and can be recorded as a D-wave from the lower thoracic spinal cord at 21 months. As all D-waves have been recorded caudal to the imSCTs, it is difficult to distinguish the contributing factor affecting the D-wave recordings in children older than 21 months: the prolonged CT maturation for the lower extremities, the individual variability of CT maturation or the influence of the imSCT.

Cerebral Cortex↗