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PubMed1993

Object-oriented data management: an approach to computerized anaesthesia documentation.

The main problem of today's anaesthesia department is that it spans a multiplicity of locations for data management dealing with data on the pre-OP, intra-OP, and post-OP situation as well as with data obtained from the laboratories, the administration, etc. In the operating room itself, numerous monitoring devices and anaesthesia machines have to be integrated into the anaesthesia documentation process. Therefore, computerized anaesthesia documentation as a part of quality control urgently needs sufficient support for handling both medical and administrative data, taking into account that the user usually is not a computer expert. We will describe an approach to solve the problem discussed applying object-oriented technology in medical data management, and a sequence of technical realization steps to bring this technology into clinical use.

Anesthesia Department, Hospital↗
PubMed1999

Private practitioners' documentation of outpatient psychiatric treatment: questioning managed care.

This study investigates how social workers, psychologists, and psychiatrists document the treatment they provide clients to managed behavioral health care organizations. The rosters of the Register of Clinical Social Workers, the American Psychological Association, and the American Psychiatric Association yielded a sample of 168 private practicing social workers, 158 psychologists, and 258 psychiatrists from across the nation. Results indicated that practitioners differed based on age, amount of time spent in private practice, racial self-identification, percentage of time with clients diminished due to communicating with managed behavioral health care organizations, and documentation of clients' prognoses. Some practitioners believe it is necessary to report treatment needs in ways to assure certification rather than in ways that accurately depict clients' clinical profiles. The ramifications for clinicians' evaluation of their own practices, reimbursement for their services, and meeting clients' needs while working under managed behavioral health care guidelines are discussed.

Adult↗
PubMed1998

Documentation of radiation-induced oral mucositis. Scoring systems.

BACKGROUND: Radiation therapy of tumors in the head and neck region is frequently associated with severe side effects in the oral mucosa which often necessitate interruption of the prescribed treatment protocol. In order to compare therapeutic strategies and, more important, in order to perform multi center studies, generally accepted scoring systems have to be applied for uniform documentation of the oral mucosal response. METHODS: Different scoring protocols are found in the literature. The scoring protocols most widely accepted are the CTC classification and the RTOG/EORTC classification. These are compared with more detailed systems. RESULTS: In the CTC classification, grading of stomatitis is included in the responses of the gastrointestinal tract and emphasizes dietary effects. For effects of radiation alone or of radiochemotherapy, the RTOG/EORTC system, focusing on therapeutic interventions, has been established. However, there are only minor differences in the grading of mucositis between these 2 protocols. Based on the RTOG/EORTC classification, Maciejewski et al. introduced a classification system with inclusion of the area affected, but also changed the sensitivity of the scores. The latter may be confusing if the source of the system used is not cited in a report. An alternative system was proposed by Dische, which in addition to objective morphologic criteria also includes the symptoms induced by the mucosal response, and hence includes some subjective aspects reported by the patient. CONCLUSIONS: For routine documentation of acute radiation side effects in the oral cavity, the German version of the RTOG/EORTC classification can be recommended. In studies with particular interest in oral mucositis, a more sensitive scoring system may be applied. In any publication concerning mucositis, a table or a detailed description of the system used should be included.

Documentation↗
PubMed1994

[Documentation in the rescue service. A basis for research and quality assurance].

Documentation of physician-staffed ambulance runs traditionally focuses on information transfer between the prehospital care provider and the receiving hospital. To use this information as a tool for research and quality assurance programs, the German Interdisciplinary Association of Critical Care Medicine developed in a consensus process a protocol for nationwide use. Protocol development was based on the question of what information can be obtained reliably in the emergency medical service (EMS) environment and what questions should be answered by data analysis. The protocol content was evaluated in several pilot studies and focuses on incidents and interventions that occur with reasonable frequency. It was taken into account that due to this approach, not all information that can possibly be obtained during the ambulance run can be documented. For data collection, the concepts of manual processing versus optical scanning are evaluated. The data analysis can serve as a basic tool for screening structure and process quality of EMS systems on a local as well as a nationwide level. During this process, areas for improvement as well as for clinical research are identified.

Documentation↗
PubMed1997

[Quality management in early clinical multiple trauma care. Documentation of treatment and evaluation of critical care quality].

Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process and to detect problems. In addition, a set of baseline data is presented. The performance in the treatment of 126 multiple injured patients was prospectively recorded from 1988 to 1993 and compared with an idealized process based upon an algorithm. The quality of present data recording was analysed, and criteria for judgement of quality of care were assessed. The algorithm was divided into 117 possible steps (one step consisting of a single decision criterion, the decision and the corresponding procedure). Per patient, only 61% +/- 12% of these steps were sufficiently documented to allow judgement. Using several criteria for assessment, the following baseline data could be observed (times shown refer to admission to the trauma room): (1) trauma room time of 129 +/- 55 min; (2) completion of basic radiological and sonographic diagnostics in 91% of patients; (3) first blood collection after 17 +/- 11 min; (4) cranial computerised tomography after 55 +/- 20 min; (5) missed injuries during the trauma room period in 32% of patients; (6) intubation after 20 +/- 19 min; (7) insertion of a chest tube after 30 +/- 17 min; (8) first blood transfusion in shock after 32 +/- 17 min; (9) transfused blood within the first hour of 4.2 +/- 2.8 units and within the second hour of 8.5 +/- 4.7 units; (10) emergency operations in shock after 98 +/- 55 min; (11) early operations after 156 +/- 69 min; (12) craniotomy after 124 +/- 37 min; (13) unplanned surgery within 24 hours after admission to the intensive care unit in 11% of patients. The study presented here supplies information on timing and other process data of the acute clinical care of seriously injured patients. In particular, the data represent indicators for the quality of emergency room management, which may be used as baseline to compose improvement measures of structure and process. The quality of data collection has to be improved for carrying out an exact analysis of the process.

Adolescent↗
PubMed1999

[Computer-based organization and documentation in orthopedics. A 5-year experience].

In the orthopedic department of the University Hospital Homburg/Saar, we use since 1993 a computer-based system for clinics organisation and documentation of operations. Hardware consists of DOS/Windows PC's in a Novell-network. Our software is a combination of database-system for managing patient-data and a special coding program for ICD and IKPM-digits. Our experience shows that computer assisted clinic-management is an effective tool to help the surgeon in planning and documentation. Until now, we used the system for 31,500 patients and 8500 operations. A flexible software can meet the requirements both of the surgeons and administration. Moreover, in the University hospital Homburg/Saar, the different departments are linked by an Intranet with connection to other scientific networks and the Internet.

Documentation↗
PubMed1999

[Structural requirements of computer-based medical documentation in a hospital setting].

During the last years physicians are confronted with a significant increase of their duties in clinical documentation. By law the medical diagnoses and procedures were linked with the aspect of liquidation. In consequence it is very important that physicians work out a detailed list of options concerning the features of the medical database, which has to cover the complete clinical data input and deliver flexible utilities for detailed evaluation. Beside documentation the system has to perform as an essential tool of clinical organisation and quality control to optimize the medical and commercial efficiency of the hospital. An open interface technology should be postulated to avoid a stand alone system in the long run.

Databases as Topic↗
PubMed2006

Comparative benefits and limitations of 18F-FDG PET and CT-MRI in documented or suspected recurrent cervical cancer.

PURPOSE: The purpose of this study was to assess the comparative benefits and limitations of (18)F-fluorodeoxyglucose (FDG) PET and CT-MRI in documented or suspected recurrence of cervical cancer after primary treatment. METHODS: Three patient groups were enrolled. Group A patients had biopsy-documented recurrent or persistent cervical cancer. Group B patients had suspicion of recurrent tumour on CT-MRI without biopsy proof and were potentially curable. Group C patients were in complete remission after previous definitive treatment for histologically confirmed cervical carcinoma but had elevated serum squamous cell carcinoma antigen (tumour marker) levels despite negative CT-MRI. Clinical management decisions were recorded with CT-MRI alone and with additional FDG PET. Discordances and concordances between CT-MRI and FDG PET results were identified and related to final diagnosis as based on histopathology or follow-up. RESULTS: A total of 150 patients (ten regions per patient) were eligible for analysis, with 58 in group A, 52 in group B and 40 in group C. For the 149 discordant regions, 126 (84.6%) had final diagnoses. Of these final diagnoses, there was additional benefit from FDG PET over CT-MRI in 73.8% (93/126), with FDG PET correcting false negatives (FNs) on CT-MRI in 74.2% (69/93) and correcting false positives (FPs) on CT-MRI in 25.8% (24/93). Among lesions confirmed by FDG PET, 75.4% (52/69) were extra-pelvic. There was additional benefit of CT-MRI compared with FDG PET in 26.2% (33/126): in nine (27.3%) CT-MRI results were shown to be true positive (TP) whereas FDG PET yielded FN results, while in 24 (72.7%) CT-MRI corrected FP results on FDG PET. Among the nine FNs on FDG PET that were identified by CT-MRI, four were extra-pelvic. Among the FPs on FDG PET that were excluded by CT-MRI, 79.2% (19/24) were extra-pelvic. CONCLUSION: For recurrent cervical cancer, the benefits of FDG PET exceed those of CT-MRI owing to the ability of FDG PET to identify extra-pelvic metastases and its higher sensitivity and specificity.

Antigens, Neoplasm↗
PubMed1999

[Documentation procedures in geriatrics--on unreliability of routinely gathered clinic data].

UNLABELLED: We analyzed quality assurance protocol records of 532 geriatric hospital patients in comparison to an administration database concerning data on "length of stay" information (LOS). Doctors handwritten quality assurance protocol records corresponded in 74.25% of cases to administration data. 14.47% of cases were registered with different LOS; 11.28% of LOS information was missing. The increasing amount of documentation tasks in German geriatric hospitals is discussed. CONCLUSION: We assume that not only discrete well known information (admission and discharge dates, LOS) are contaminated by documentation failure but also data on functional status of geriatric patients which may have important influence on external data processing.

Aged↗
PubMed2006

Validation of an instrument for the documentation of clinical pharmacists' interventions.

OBJECTIVE: To validate an instrument for documentation of clinical pharmacy interventions in French speaking hospitals in France and outside of France. METHOD: A panel of 12 French speaking clinical pharmacists (six from France; six from French speaking countries) was asked to analyse a set of 60 pharmacist's interventions on drug prescription. They used a form including (1) the identification of the drug related problems (DRPs) (10 items), (2) the pharmacist's intervention (7 items). We assessed the level of agreement between the 12 pharmacists on the test DRPs and on the interventions. MAIN OUTCOME MEASURES: Kappa coefficient of concordance was used to assess the level of agreement between experts for DRPs and interventions. We also assessed the userfriendliness of the instrument using Likert scales. RESULTS: The level of concordance observed in the validation was 0.76 for DRPs and 0.89 for the type of intervention. Eleven experts out of 12 were "very satisfied" or "satisfied" and one "not satisfied" with the tool. Ten out of the 12 experts were ready to use it in daily practise. CONCLUSION: The present instrument proposed by the French Society of Clinical Pharmacy (SFPC) is the first coding system for pharmacist's interventions with a French interface. The validation process using a standard statistical methodology helps support the external validity of our tool. The level of concordance between users can be considered as satisfactory, allowing the use of the tool in daily clinical pharmacy practise. To enhance the diffusion of the instrument and of the general process of routine documentation of interventions, a spreadsheet is provided on the French Society of Clinical Pharmacy website.

Documentation↗
PubMed1980

Data structures for medical documentation.

The paper describes a method to construct data base structures for patient-related documentation. The data base structures are formed over suitable classes. Functional dependences are only investigated regarding these classes. Structuring items by means of arbitrary relations are possible, too. The results are well-formed flexible data structures which can serve as a common functional basis for many documentation projects.

Computers↗
PubMed1991

The development of new documentation for use in cases of major trauma.

In response to recent reports questioning the adequacy of management of major trauma in the United Kingdom, the routine for handling such emergencies in one district general hospital was examined. Deficiencies in the current system of management were identified and are described. In order to improve the standard of care a protocol for the assessment and resuscitation of the seriously injured was devised. This protocol provided for the formation of a Trauma Team and laid down guidelines as to the severity of injury that required the attendance of this team. In addition, a new form of documentation was designed to facilitate the recording of injuries, resuscitation measures required and physiological parameters. This documentation is described in detail. These measures have been favourably received by medical and nursing staff and have stimulated interest in the management of major injuries.

Documentation↗
PubMed1992

Resistance to documentation--a nursing research issue.

In this case study, the views of a sample of four hospital nurses were elicited to determine underlying causes of persistent antipathy towards documentation in patients' charts. The results of this review supported a common belief that resistance to charting is influenced by extrinsic, or environmental factors, such as inflexibility of charting systems and insufficient allocation of time. In addition, intrinsic factors or cognitive and psychosocial factors, not emphasized in earlier studies, such as lack of confidence about written expression, a tendency to succumb to group norms governing charting and difficulty in articulating the nature of nursing practice, surfaced as impediments to documentation. This review suggests that a broader study approach is required; one that addresses intrinsic, as well as extrinsic, factors.

Adult↗
PubMed1995

Cleft malformation of lip, alveolus, hard and soft palate, and nose (LAHSN)--a critical view of the terminology, the diagnosis and gradation as a basis for documentation and therapy.

The hope for the improvement of the treatment of patients with a cleft malformation of lip, alveolus, hard and soft palate, and nose (LAHSN) is to review and to compare new concepts and methods. But research in this way presumes an exact, reliable and reproduceable diagnosis and documentation. This article reviews previously published diagnosis and documentation systems, and also suggests a concise and simple system to record a cleft lip and palate diagnosis. The anatomical regions of the cleft are considered as well as their extent. A three way division to record the extent of the malformed regions is proposed. It is a extensively used diagnosis recording system.

Alveolar Process↗
PubMed2004

Positive straight-leg raising in lumbar radiculopathy: is documentation affected by insurance coverage?

OBJECTIVE: To evaluate whether differences exist in documentation of straight-leg raising (SLR), based on insurance coverage. DESIGN: Retrospective study. SETTING: Managed care organization (MCO). PARTICIPANTS: Two hundred people with a diagnosis of lumbar radiculopathy or herniated disk were referred to an MCO for authorization of further treatment. Half were self-directed under a personal injury program (PIP) after automobile collisions, and half were covered under a managed care workmen's compensation (WC) program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Documentation of an SLR test, strength, sensation, and/or reflexes were eligible for the study. The results of SLR were coded as 0, 1, or 2, for absent, positive unilateral, and positive bilateral, respectively. Additional information included subject age, sex, date of injury, provider type, and presence of attorney representation RESULTS: A positive (unilateral, bilateral) SLR in women was 7.4 times more likely if they were covered by PIP than by WC (95% confidence interval [CI], 1.4-38.7; P=.018). For men, a positive SLR was 23.5 times more likely if they were covered by a PIP (95% CI, 2.9-189.9; P=.003). The odds of bilateral SLR (radicular pain on both sides) were even more strongly associated with type of reimbursement. For women, bilateral SLR was 105.1 times more likely if they were covered by a PIP than by WC (95% CI, 11.1-992.6; P<.001). For men, bilateral SLR was 38.9 times more likely if covered by a PIP (95% CI, 11.3-133.6; P<.001). CONCLUSIONS: Reasons for reporting higher rates of positive SLR in the PIP group include an added incentive to treat, poor knowledge of proper interpretation of the SLR test, and/or an increased exaggeration of symptoms.

Accidents, Traffic↗
PubMed2005

Introducing DoT-U2--an XML-based knowledge supported checklist software for documentation of a newborn clinical screening examination.

In a project concerning the German newborn screening examination "U2" we developed a software system called DoT-U2 for concurrent documentation at the point of care. Physicians can enter findings in(to) a tree structured protocol with management of logical dependencies. Additionally, all findings except free text annotations can be entered by speech recognition. The software system program is written in Java and uses separate XML-based modules both for knowledge and language representation. It can, therefore, easily be adapted to other languages and further documentation scenarios. We showed the high flexibility of the software system by integrating it in a completely new setting in Salt Lake City without major problems. We found that modular software development with platform independent Java and XML leads to highly flexible software which can be adapted to very different scenarios without knowing their requirements ahead of time.

Decision Making, Computer-Assisted↗
PubMedDate not supplied

Detection and documentation of dementia and delirium in acute geriatric wards.

Detection of cognitive impairment among hospitalized older individuals has shown to be insufficient. A point prevalence study in two geriatric hospitals in Helsinki, Finland, was performed among 219 acutely ill individuals over 70 years to assess the detection of dementia and delirium. Documentation of dementia and delirium in medical records, and recordings of confusional symptoms in nurses' notes were compared with the researchers' diagnosis made after a detailed assessment of cognitive status. The cognitive decline was mentioned in medical records in 70/88 (79.5%) of the cases. Cognitive testing was performed on 42/88 (47.7%) of the dementia patients, and the diagnosis of dementia was recorded in 47/88 (53.4%) of them. A specific etiological diagnosis was recorded in only 4/88 (4.5%) cases. Cognitive impairment in at least one of these four means was recorded in 80/88 (90.9%) of cases (sensitivity 0.93). Eight patients had a false-positive diagnosis of dementia (specificity 0.94). Delirium was diagnosed in 77 (35.2%) patients by the researchers, but it was recorded in only 31/77 (40.3%) in medical records. In 64/77 (83.1%) cases signs of confusion were recorded in nurses' notes. Poor detection and documentation may lead to undertreatment of both disorders.

Acute Disease↗
PubMed2005

Developing terminology for documenting perioperative nursing interventions.

OBJECTIVE: To develop terminology for documenting perioperative nursing interventions. METHOD: Nursing documentation of 250 patients was explored by content analysis. The study was conducted to validate further the Perioperative Nursing Data Set (PNDS) in Finland. The data included 3442 terms that were clustered into 104 nursing interventions. A Delphi-panel (N=5) evaluated the relevance of each term on a scale from 1 to 4. The structure of each nursing intervention was checked to meet the minimum requirements of the ISO reference terminology model for nursing action concepts. Finally, the nursing interventions were compared with the original PNDS-interventions. RESULTS: The Delphi-panel accepted 98 nursing interventions with Content Validity Index from 0.88 to 1.0. Of the 133 nursing interventions in the PNDS, 60% (n=80) were covered by nursing interventions identified in this study. A notable portion of the nursing interventions related to preventive aspects of perioperative care and the patients' coping with perioperative experience. CONCLUSION: The findings supported the need for cross-cultural validation of a nursing language prior to clinical implementation. The ISO reference terminology model is recommended as framework in constructing concepts for nursing interventions in a regular form.

Delphi Technique↗