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Planning and documentation. Addressing patient needs in a day surgery setting.

Day surgery has reduced the time allowed for patient contact, but it has not reduced the need for assessment, planning, and delivery of patient care. Day surgery, however, has shifted some responsibility from nurses to patients and their families. Our goals in developing a preoperative assessment plan were to ensure consistent and thorough patient assessment; enhance problem identification and guide appropriate interventions; provide evaluations based on the needs of the day surgery patient; assist patients and families in assuming increased responsibility for postoperative care; provide achievable and manageable documentation of patient information gathered in a compressed amount of time; and facilitate communication between the patient and the health care team. We feel our assessment documenting system meets these goals and allows nurses and patients to adapt to the changes in traditional roles both parties experience when day surgery procedures are performed.

Ambulatory Surgical Procedures↗

Image documentation of endoscopic findings in ulcerative colitis: photographs or video clips?

BACKGROUND: Previous studies have shown deficiencies in the endoscopy reports and substantial interobserver variation in the assessments of endoscopic findings. The aim of this study was to determine how to perform systematic digital image documentation in ulcerative colitis and to evaluate if mucosal inflammation is assessed equally on a still image and on a video clip. METHODS: Eighteen video clips and their corresponding photographs that visualize different severities of ulcerative colitis were shown in randomized order to 20 experienced endoscopists. They assessed the mucosal inflammation of each image twice on a visual analog scale. Three comparisons were performed between the video clips, the photographs, and the video clips to the photographs, respectively. RESULTS: The mean score of the inflammation of the video clips at tape 1 and 2 was 4.74: 95% confidence interval (CI)[4.41, 5.08] and 4.90: 95% CI[4.56, 5.24), respectively, and of the photographs 4.53: 95% CI[4.19, 4.88] and 4.43: 95% CI[4.09, 4.77], respectively. The first answer explains 83% of the variation in the second answer for all comparisons, and the agreement index ranged from 0.38 to 0.42. CONCLUSIONS: The mucosal inflammation might be documented nearly as well with a still image as on a video clip. Systematic use of still images probably improves the endoscopy reports by adding more objective information about the mucosal inflammation.

Colitis, Ulcerative↗

Structured documentation.

Structured documentation is a concept-oriented method of capturing clinical information that can be shared readily through automated systems. Standards are evolving for controlled vocabularies that are applicable to various aspects of clinical medicine. Vocabulary expressiveness and the significant preparatory work needed to use structured terms are hindrances to the rapid acceptance of these tools; however, the benefits of increased efficiencies, data sharing, and automated triggers may outweigh the cost of these hindrances. Understanding the basic principles of structured documentation and defining the use of the structured data within a practice allows an organization to select a tool that most closely fits its needs.

Documentation↗

Billing, coding, and documentation in the critical care environment.

Optimal conduct of modern-day physician practices involves a thorough understanding and application of the principles of documentation, coding, and billing. Physicians' role in these activities can no longer be secondary. Surgeons practicing critical care must be well versed in these concepts and their effective application to ensure that they are competitive in an increasingly difficult and demanding environment. Health care policies and regulations continue to evolve, mandating constant education of practicing physicians and their staffs and surgical residents who also will have to function in this environment. Close, collaborative relationships between physicians and individuals well versed in the concepts of documentation, coding, and billing are indispensable. Similarly, ongoing educational and review processes (whether internal or consultative from outside sources) not only can decrease the possibility of unfavorable outcomes from audit but also will likely enhance practice efficiency and cash flow. A financially viable practice is certainly a prerequisite for a surgical critical care practice to achieve its primary goal of excellence in patient care.

Accounting↗

Peer review of social work documentation.

Peer review of social work documentation has helped promote the uniformity and consistency with which services are delivered; and social workers are exposed to the professional practice of their colleagues, since all staff members participate in conducting peer reviews. The system also helps identify areas of weakness or deficiency common to staff members. The detection of such patterns is the responsibility of the peer review committee, which brings them to the attention of the social work service management and of the service's QA committee. Corrective action is then taken to remedy identified problems. The system also has the potential to help identify patient problems and needs not met by the existing system of health care delivery; such gaps in service can then be brought to the attention of the management of the medical center for consideration and possible resolution. By focusing on documentation elements as indicators of high-quality and appropriate social work intervention, the peer review system used by the social work service has helped enhance social worker performance and service delivery.

Documentation↗

Motor vehicle crashes and seat belts: a study of emergency physician procedures, charges, and documentation.

STUDY OBJECTIVE: To study emergency physician documentation of seat belt use, practice patterns, and charges for patients with different restraints involved in motor vehicle crashes. DESIGN: Retrospective examination of 2,239 emergency department records during a 5-month period. PARTICIPANTS: Patients from four community EDs and one Level I trauma center ED. RESULTS: Documentation of seat belt use for motor vehicle crash occupants was reported in 70% of the ED records reviewed. Only 64.5% of the records from the four community hospital EDs recorded seat belt use, compared with 81.7% of the records from the trauma center ED (P < .001). The unbelted group had a greater mean number of physician procedures performed (1.4 versus 1.2; P < .001) and more radiographs of the face and skull ordered (11.9% versus 8%, P < .01). Seat belt users had a higher average number of cervical-spine radiographs ordered than did nonusers (71.5 versus 65.7; P < .05). Physician charges for unbelted patients were higher compared with those for belted patients, averaging $22.00 more per patient (P < .001). CONCLUSION: Emergency physician practice patterns reflect the distribution of injuries associated with seat belt use and nonuse. Reduced physician charges for belted patients contributed to health care cost savings. Emergency physicians should be encouraged to consistently obtain and record whether an individual was wearing a seat belt during a motor vehicle crash.

Accidents, Traffic↗

Documentation in bronchology.

With the performance of more endoscopic procedures and newly developed diagnostic and therapeutic modalities, a wealth of information around the actual procedure is created. To date, accepted guidelines for standardized documentation are lacking. The authors present recommendations for minimal guidelines that may help to facilitate good documentation and also address future developments that will be possible with the help of computer-assisted approaches.

Bronchoscopy↗

Documentation and informed consent.

Documentation remains the key factor that leads to success or failure of a claim in a significant number of cases. Since the time of a trial is often years later, an accurate memory can only be reflected by the records kept by the physician in question. This article focuses on developing good habits of documentation in areas such as medical record maintenance, handwriting, informed consent, and record tampering. Guidelines for improved record keeping are also presented in this article.

Documentation↗

Photographic documentation of hair growth in androgenetic alopecia.

The challenge of useful serial photographic documentation of hair loss can be met by using a regimented approach at each photographic session. Patient outcomes that are better documented allow for more informed decisions to be made about the course of therapy by both the physician and the patient.

Alopecia↗

HepatoConsult: a knowledge-based second opinion and documentation system.

HepatoConsult is a publicly available knowledge-based second opinion and documentation system aiding in the diagnosis of liver diseases. The positive results of a prospective diagnostic evaluation study encouraged its use in clinical routine, although the available hardware infrastructure was not optimal. The comments of the physicians who used the system confirmed the results of the study and showed that the time for data entering is acceptable and the implicit standardization of terminology and documentation is welcome. Suggestions for improvement included the interface to enter data more easily, the scope to be usable for more patients and the additional capability to generate medical reports from the data.

Artificial Intelligence↗

Documentation in laparoscopic surgery.

Technological developments have increased tremendously the possibilities for the application of image documentation techniques in gynaecological laparoscopy. Increased quality of optical endoscopes, powerful light sources, highly sensitive photographic films and miniature electronic video cameras have largely removed the barriers to efficient documentation. This equipment is no longer considered to be only for 'hobbyists', but has become an essential part of diagnostic and surgical laparoscopy. Future developments can only increase its applications further.

Diagnostic Imaging↗

Hospice patient advocacy through complete documentation.

The hospice movement was built around patient choice and autonomy. Because of recent Medicare scrutiny, some patients are being denied the choice of hospice at the end of their lives. Hospice staff must learn how to accurately and completely document the care they provide so that patients are not denied access to care because they do not "meet the guidelines" or payment is denied as a result of inadequate or unclear documentation.

Documentation↗

A guide to revising the postanesthesia care unit documentation record.

The environment of the PACU is changing rapidly, as are the standards, protocols, and requirements of documentation. Nursing care activities must be captured in a timely, accurate, and efficient manner that reflects the standards of care and quality practice, while reducing the amount of actual writing required. This article reviews the available literature and defines a process to guide one through the revision of a documentation record.

Documentation↗

Using the biologic license application or new drug application as a basis for the common technical document.

With the introduction of the common technical document (CTD), many writers in the biotech and pharmaceutical industries are now required to submit dossiers in this format. The format of the CTD is not extremely difficult from the familiar documents of the Biologic License Application (BLA) or New Drug Application (NDA). The CTD can be mapped to existing areas of the BLA or NDA. The components of the CTD are discussed and references to the current guidance worldwide are provided to assist the writer.

Documentation↗

Clictate: a computer-based documentation tool for guideline-based care.

The use of computer-based documentation tools confers many benefits to the delivery of evidence-based health care. We developed Clictate, a structured reporting environment that utilized standard Windows-based data entry constructs and natural language generation. Clictate has been in use for over 3 years by pediatric providers in an ambulatory setting. More than 50% of our providers use Clictate during the patient encounter. This report describes our results to date, and suggests future opportunities for research and development in the area of computer-based documentation.

Child↗

[Computer based documentation of ultrasound data].

Usually, hospitals and private doctors are well equipped with computers. However, the documentation of ultrasound data is commonly paper-based. The paper presents a computer-based ultrasound data recording and reporting, using the ultrasound documentation software Digisono.

Cost-Benefit Analysis↗

[The path from science to the practicing surgeon. Engagement of documentation of the Swiss Academy of Medical Sciences for providing evidence-based medicine].

The flood of information that comes along with the rise of electronic media has changed the expectations towards the Documentation Service of the Swiss Academy of Medical Sciences (DOKDI): Evidence Based Medicine (EMB) in particular not only demands procurement of information, but also a selection regarding quality and relevance: The question arising out of the clinical situation requires an answer correct in its content and helpful in the specific situation. Getting an idea of what evidence exists about the correctness of a certain procedure through critical lecture is an ideal often obstructed by lack of time and methodical problems in the practice; therefore, one often has to rely on evidence acquired through others and consult e.g. the Cochrane Library. DOKDI commits itself to the development of systematic reviews as well as to the dissemination of evidence found by using its experience in the documentation with electronic media and by providing the corresponding infrastructure. In addition to these activities, the Academy has spoken a grant for the training of EBM-Tutors. During a weekly workshop held in Oxford, clinicians will be trained as EBM-Tutors. This will allow an increasing number of EBM-Workshops held in Switzerland in the future.

Academies and Institutes↗

Creating a comprehensive training documentation program.

The regulations mandate that individuals involved in research animal care and use receive adequate training, but they fail to address the documentation of the training. The authors provide guidelines for training documentation and, as an example, describe the program in place at the University of Pennsylvania.

Animal Welfare↗