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At least 991 records · Page 55Linked to original sources
PubMed2005

Semantic clinical guideline documents.

Decision-support systems based on clinical practice guidelines can support physicians and other healthcare personnel in the process of following best practice consistently. A knowledge-based approach to represent guidelines makes it possible to encode computer-interpretable guidelines in a formal manner,perform consistency checks, and use the guidelines directly in decision-support systems.Decision-support authors and guideline users require guidelines in human-readable formats in addition to computer-interpretable ones (e.g., for guideline review and quality assurance). We propose a new document-oriented information architecture that combines knowledge-representation models with electronic and paper documents. The approach integrates decision-support modes with standard document formats to create a combined clinical-guideline model that supports on-line viewing, printing, and decision support.

Decision Making, Computer-Assisted↗
PubMed2005

An environment for document engineering of clinical guidelines.

In this paper, we present the G-DEE system, a document engineering environment aimed at clinical guidelines. This system represents an extension of current visual interfaces for guidelines encoding, in that it supports automatic text processing functions which identify linguistic markers of document structure, such as recommendations, thereby decreasing the complexity of operations required by the user. Such markers are identified by shallow parsing of free text and are automatically marked up as an early step of document structuring. From this first representation, it is possible to identify elements of guidelines contents, such as decision variables, and produce elements of GEM encoding, using rules defined as XSL style sheets. We tested our automatic structuring system on a set of sentences extracted from French clinical guidelines. As a result, 97% of the occurrences of deontic operators and their scopes were correctly marked up. G-DEE can be used for various purposes, from research into guidelines structure to assisting the encoding of guidelines into a GEM format or into decision rules.

Data Display↗
PubMed2005

Integrating microarray gene expression object model and clinical document architecture for cancer genomics research.

Systematic integration of genomic-scale expression profiles with clinical information may facilitate cancer genomics research. MAGE-OM (Microarray Gene Expression Object Model) defines standard objects for genomic but not for clinical data. HL7 CDA (Clinical Document Architecture) is a document model for clinical information, describing syntax (generic structure) but not semantics. We designed a document template in XML Schema with additional constraints for CDA to define content semantics, enabling data model-level integration of MAGE-OM and CDA for cancer genomics research.

Gene Expression Profiling↗
PubMed2000

Appropriate documentation, billing and coding in interventional pain practice.

Appropriate documentation, billing and coding in interventional pain practice is a crucial issue with a wide arena of regulatory reforms. There have been reports of billions of dollars in losses in health care fraud. Office of Inspector General reports a massive war on health fraud. Substantial savings from prepayment audits for Part B in 1999, and continued criminal filings by the Department of Justice indicate persistence of Health Care Financing Administration to combat fraud. In addition President Clinton's initiatives to fight Medicare waste, fraud, and abuse have created increased fear of investigation or prosecution among physicians, leading to changes in their practice patterns. Documentation of medical necessity with coding that correlates with multiple components of the patient's medical record, operative report, and billing statement is important. This review describes the regulatory issues, steps in documentation of medical necessity, appropriate billing and coding, and examples of codes describing CPT 1999 and 2000 for a multitude of procedures. These illustrations and the information provide practical considerations for the use of interventional techniques in the management of chronic pain based on the current state of the art and science of interventional pain management, rules and regulations. However, this article and its descriptions do not constitute legal advice.

Journal Article↗
PubMed2006

API expert consensus document on management of ischemic heart disease.

The incidence of coronary artery disease (CAD) has dramatically increased in India during the recent years. There are two facets of CAD: stable CAD and unstable CAD which includes patients with acute coronary syndrome (unstable angina, non-ST elevation myocardial infarction, ST elevation myocardial infarction). The treatment of stable CAD (stable angina) includes anti-anginal medication, medication to modify atherosclerosis and aggressive treatment of causative risk factors. Those patients with stable CAD who have symptoms refractory to medical treatment usually require coronary angiography to be followed by either percutaneous or surgical revascularization. Percutaneous coronary revascularization using drug eluting stents has been a major revolution during the last five years for symptomatic relief of angina in symptomatic CAD and can be applied to large subsets of patients. Off-pump surgical revascularization using arterial grafts is a major advance and bypass surgery continues to remain treatment of choice in diabetics with multi-vessel CAD, left main CAD and in patients with multivessel disease and impaired ventricles. Acute coronary syndromes are usually caused by plaque rupture with resultant thrombus and present as unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). It is now increasingly realized that these patients (particularly the one with high risk) are best managed in advanced cardiac care centres with facilities for cardiac catheterization laboratory, percutaneous coronary interventions and coronary bypass surgery. In both, NSTEMI and STEMI aggressive medical management involving nitrates, ACE inhibitors, beta-blockers, dual anti-platelet agents, heparin and statins are recommended. High risk patients with NSTE-ACS require use of glycoprotein IIa / IIIb inhibitors along with early invasive approach involving coronary angiography, angioplasty using drug eluting stent and in some patients bypass surgery. Early reperfusion is key to management of patients presenting with STEMI. If facilities are available, primary percutaneous coronary intervention (angioplasty with stenting) is treatment of choice for patients with STEMI. In our country, thrombolysis still remains the most frequently utilized reperfusion therapy and all efforts should be devoted to provide this therapy at the earliest. All high risk patients with STEMI (including cardiogenic shock) are best treated in higher centres and these patients should be promptly transported to such centres. Early coronary angiography is recommended for majority of patients following thrombolysis for risk stratification and further treatment. In acute coronary syndromes there is drift towards early invasive treatment and this is reflected in marked increase in cardiac care (catheterization laboratories and cardiac surgery centers) facilities throughout India. All patients with CAD require life-long supervised treatment which includes medication, control of risk factors and lifestyle modification. Avoidance of smoking, heart healthy diet, proper exercise, ideal weight management are important for all the patients. Statins, ACE inhibitors, beta-blockers, antiplatelet agents have a great role to play in treatment and prevention and these drugs should be utilized under medical supervision. It is important that the medical profession play an important role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection and management of cardiac disorders. The American College of Cardiology (ACC), American Heart Association (AHA), European Society of Cardiology (ESC), Society for Cardiovascular Angiography and Interventions (SCAI) and several other societies engage in production of guidelines in the area of cardiovascular diseases from time to time. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The aim of the guidelines is to improve the patient care. The ultimate judgement regarding the care of the particular patient is to be made by the clinician / healthcare provider keeping in mind all the circumstances. The incidence and prevalence of coronary artery disease (CAD) has increased tremendously in India during the last two decades and this change is largely attributable to lifestyle changes. There has also been a rapid progress in the treatment of CAD with proliferation of specialized cardiac care units, intensive care units, cardiac catheterization laboratories and facilities for bypass surgery. It is estimated that there are over 400 catheterization laboratories currently in India and nearly half of them are located in six major cities. The increase in disease and availability of facilities has resulted in a dramatic change and the focus is shifting from only medical treatment to invasive treatment. This document is an expert consensus document which has been prepared by going through the available guidelines and other relevant literature on the subject. The experts have performed a formal review of the literature and have weighed the strength of evidence for or against a particular therapy as it can be applied in Indian scenario. The consensus document deals with the management of ischemic heart disease (IHD) under following sections: 1) Stable Angina 2) Non ST Elevation Acute Coronary Syndrome (NSTE-ACS) 3) ST Elevation Acute Coronary Syndrome (STE-ACS) or Acute Myocardial Infarction (AMI).

Acute Disease↗
PubMed2006

Standardized exchange of clinical documents--towards a shared care paradigm in glaucoma treatment.

OBJECTIVES: The exchange of medical data from research and clinical routine across institutional borders is essential to establish an integrated healthcare platform. In this project we want to realize the standardized exchange of medical data between different healthcare institutions to implement an integrated and interoperable information system supporting clinical treatment and research of glaucoma. METHODS: The central point of our concept is a standardized communication model based on the Clinical Document Architecture (CDA). Further, a communication concept between different health care institutions applying the developed document model has been defined. RESULTS: With our project we have been able to prove that standardized communication between an Electronic Medical Record (EMR), an Electronic Health Record (EHR) and the Erlanger Glaucoma Register (EGR) based on the established conceptual models, which rely on CDA rel.1 level 1 and SCIPHOX, could be implemented. The HL7-tool-based deduction of a suitable CDA rel.2 compliant schema showed significant differences when compared with the manually created schema. Finally fundamental requirements, which have to be implemented for an integrated health care platform, have been identified. CONCLUSIONS: An interoperable information system can enhance both clinical treatment and research projects. By automatically transferring screening findings from a glaucoma research project to the electronic medical record of our ophthalmology clinic, clinicians could benefit from the availability of a longitudinal patient record. The CDA as a standard for exchanging clinical documents has demonstrated its potential to enhance interoperability within a future shared care paradigm.

Computer Communication Networks↗
PubMed1991

Dental photograph standardization for case documentation.

Photography has become an important tool for case documentation, patient education, and case presentation. Standardization of dental photographs is especially important for accurate documentation of the changes that occur as a result of treatment. A protocol for standardization based on anatomic landmarks and patient and camera positions is presented. Specific photographic views are recommended for complete case documentation. The need for written consent before photographing a patient is also discussed.

Dental Records↗
PubMed1991

Documentation of discharge teaching before and after use of a discharge teaching tool.

Newly diagnosed Type 1 diabetic patients and their parents have a great deal of complex teaching needs before discharge. Documenting the discharge teaching and planning is an important nursing responsibility. The documentation of discharge teaching ensures the highest quality of patient care. With pressures from insurance companies and diagnostic-related groups, nurses must perform extensive discharge teaching in an abbreviated time frame. A Diabetic Discharge Teaching Tool (DDTT) is an instrument that can facilitate concise documentation and assist in developing the plan of care over the ensuing hours or days.

Adolescent↗
PubMedDate not supplied

A creative approach to comprehensive i.v. therapy documentation.

Specific, thorough documentation is required to provide continuity of care to patients receiving intravenous therapy. In addition, though the Joint Commission on Accreditation of Healthcare Organizations' regulations require documentation of patient teaching and patient response to treatment, this information is frequently omitted from I.V. therapy records. A checklist was devised to provide a systematic, comprehensive method of documenting I.V. therapy procedures.

Catheters, Indwelling↗
PubMedDate not supplied

[A new concept of school medical documentation--recording health data on a personal computer].

A revised concept of health data documentation in schools was tried out in a pilot project in two districts of the city of Hamburg over a period of 2 years. Standardised findings comparable with the so-called "Bielefeld Model" are documented in an EDP-compatible school health record book and fed into a personal computer by members of the school physician's team. These data supply a survey of the state of health of a part of our population and are thus of the nature of a complete cross-sectional and longitudinal study. They can supply the basis for health policy measures if the quality of data coverage and documentation is assured. Examples illustrate the possibility of discovering regionally different characteristics on the spot; supraregional evaluation is possible by data transfer to data carriers after anonymisation. Acceptance by school physicians and parents of children examined according to this new concept is high. Measures have been taken to initiate this method in all Hamburg districts during 1990.

Child↗
PubMed1988

Documentation of myofascial trigger points.

Two basic diagnostic features of myofascial trigger points (TPs), namely, local tenderness and alteration of tissue consistency (such as in taut bands, muscle spasm), can be documented quantitatively by simple hand-held instruments. A pressure threshold meter (algometer) assists in location of TPs and their relative sensitivity. A side-to-side difference exceeding 2kg in comparison with normal values indicates pathologic tenderness. The effect of treatment can be quantified. Pressure tolerance, measured over normal muscles and shin bones, expresses pain sensitivity. Myopathy is suspected if muscle tolerance drops below bone tolerance. Tissue compliance measurement documents objectively and quantitatively alteration in soft tissue consistency. Muscle spasm, tension, spasticity, taut bands, scar tissues, or fibrositic nodules can be documented. The universal clinical dynamometer is used as part of a physical examination to quantify weakness. Thermography (heat imaging) demonstrates discoid shaped hot spots over TPs. Muscle activity, spasm, or contraction is visualized as increased heat emission in the shape of the active muscle.

Compliance↗
PubMed1987

Tissue compliance meter for objective, quantitative documentation of soft tissue consistency and pathology.

A new instrument is described, the tissue compliance meter (TCM), for quantitative and objective recording of soft tissue consistency. This quality is appreciated at present only by the subjective method of palpation. Use of the TCM therefore offers a method to quantify palpation of tissue consistency and to document findings objectively. The handheld instrument allows immediate and simple reading of the depth of penetration of a rubber disc at a known pressure. The relation between the achieved penetration and employed pressure expresses the compliance. The TCM consists of a rubber disc with the surface of 1 cm2 attached to a force gauge. The depth of penetration of the rubber tip is indicated by a disc which slides on the shaft of the force gauge. Normal values were established for men and women over muscles which are frequently affected by spasm. Tissue compliance measurement can document changes in soft tissue consistency which occur in muscle spasm, spasticity, swelling, tumors, lumps, hematomas, etc. Use of the TCM provides the most sensitive and earliest objective indication of either healing and resolution in soft tissue pathology or occurrence of complications. Changes in muscle tone such as reduction of spasm, tension, or spasticity can be recorded. The effects of different types of physical therapy can thus be documented objectively.

Connective Tissue↗
PubMed1985

Documenting workload to better integrate clinical and distributive services.

Use of workload and work-flow documentation in two pharmacy satellites to evaluate pharmacists' productivity is described. Workload was evaluated during 14 consecutive days in May 1983 and 7 consecutive days in May 1984. All pharmacists and technicians working in the satellites recorded times for their activities on a form that listed every possible activity; interruptions such as answering the telephone, responding to walking requests, replacing stock, and lunches and break times were also recorded. Concurrently, the clinical coordinator observed and evaluated work performed for four-hour time blocks at least once each day. Analysis of workload and work-flow information identified problems with scheduling, priorities, interruptions, and pharmacists' knowledge of clinical pharmacy practice. Based on these observations, the following changes were implemented: pharmacists were scheduled to work either inside or outside the satellites for two-week or one-month time periods, priorities were assigned to certain tasks performed inside or outside the satellites, job assignments were made based on the pharmacist's capabilities and the needs of the patient-care areas, a form for documenting potential problem orders was created, and pharmacists were evaluated monthly and given one-on-one instruction by the clinical coordinator. Documentation of time use identified problems and led to changes in assignments that better integrated clinical, educational, and distributive responsibilities for the purpose of providing more efficient and effective services.

Appointments and Schedules↗
PubMedDate not supplied

Dental record documentation in selected ambulatory care facilities.

Having recognized the differences in financial incentives between institutional providers and private practitioners participating in the Medicaid program, the New York State Health Department developed a streamlined mechanism of prior approval for 13 selected institutional providers of dental care. As part of the evaluation of this process, a retrospective audit of 316 dental records was conducted to assess the level of documentation present in the dental record. A followup audit was conducted 3 months after implementation of a plan to correct any deficiencies identified. More than 50 percent of the facilities were unable to present all the records requested at the time of the initial audit. Few of the audited records were free of deficiencies, and documentation of the results of the intra-oral examination was lacking in most facilities. The followup audit demonstrated statistically significant improvement in the level of record documentation. These results demonstrate that, even when good recordkeeping procedures were identified and agreed to by these institutional dental providers, performance was inadequate. However, the study also demonstrates that adequate records can be kept if sufficient incentives are provided. Efforts to evaluate retrospectively the delivery of dental care that are dependent on the dental record as a primary data source are unlikely to succeed unless incentives to encourage good recordkeeping are incorporated. Further research is needed to develop appropriate incentives that would operate in other practice settings.

Dental Clinics↗
PubMed1995

Nicotine and addiction. The Brown and Williamson documents.

OBJECTIVE: To learn how nicotine has been regarded by a major tobacco company. DATA SOURCES: Documents from Brown and Williamson Tobacco Corporation (B&W), the British American Tobacco Company (BAT), and other tobacco interests provided by an anonymous source, obtained from Congress, and received from the private papers of a former BAT officer. STUDY SELECTION: All available materials, including confidential reports regarding research and internal memoranda exchanged between tobacco industry lawyers. CONCLUSIONS: During a period of 22 years (1962 to 1984), employees of B&W and BAT conducted research and commented on the pharmacology of nicotine. They consistently regarded nicotine as the pharmacological agent that explained tobacco use. In the early part of the period under study, officials of the companies wrote about nicotine addiction explicitly. Inhalation of cigarette smoke by the consumer was recognized throughout the period as necessary for the normal function of a cigarette. The documents contain little indication that research was conducted on either the taste or the flavor of nicotine. The documents reveal an intention on the part of B&W and its corporate parent to affect the function of the body with nicotine.

Commerce↗
PubMed1994

Educating educators in GLP documentation.

Professionals in academia usually are not trained in documenting their research activities to the extent and detail mandated under Good Laboratory Practice (GLP) regulations. To assist researchers at the University of Arizona in implementing a GLP program, the university's Quality Assurance Unit (QAU) has written procedures and checklists detailing various aspects of GLPs. Since a key to the successful implementation of GLPs is comprehensive documentation in laboratory notebooks of research activities, information and guidelines are provided in a checklist format. Training seminars are also provided to discuss the use of the checklists. Checklists in conjunction with training seminars provide an important mechanism to ensure that all appropriate information has been recorded for verifiable, reproducible, and traceable documentation of project study results.

Arizona↗
PubMed1995

[Documentation in child and adolescent psychiatry: experiences from a multicenter study].

Reasons for the need for a coordinated multi-centered documentation for quality safeguarding are given. Based upon experiences with patient documentation, where 13 child and youth psychiatries in the German states Lower Saxony and Bremen participated for one year, problems with a documentation system are shown and discussed. In conclusion recommendations are given for carrying out such studies, which will become more important in the framework of quality safeguarding in child and youth psychiatries.

Adolescent↗