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At least 1,063 records · Page 59Linked to original sources
PubMed2003

Effects of 'pain-advisers': district nurses' opinions regarding their own knowledge, management and documentation of patients in chronic pain.

This study investigated whether district nurses' opinions changed after the education and introduction of district nurses as 'pain-advisers' at primary health care centres (PHCCs) regarding working conditions and satisfaction with pain control management at their PHCCs, their own knowledge of pain control and satisfaction with their own pain control management, pain assessment and nursing documentation of patients with chronic pain conditions. A study area (SA) with five PHCCs and a control area (CA) with seven PHCCs were selected. In the SA, 28 and in the CA, 25 district nurses answered a questionnaire both before and after the introduction of the 'pain-advisers' into the SA. The district nurses in both areas in 1996 and 1998 considered many aspects of pain management to be unsatisfactory. According to the district nurses in the SA, several statistically significant improvements were achieved after the introduction of the 'pain-advisers'; more district nurses reported that pain policies or other written information were now available at their PHCCs, that they were more satisfied with present overall routines at their PHCCs, that a better pain control was applied at their PHCCs regarding patients with leg ulcers, that they themselves to a greater extent performed individual pain assessments of the patients and that they more often used pain visual analogue scales to assess the patients' pain and to evaluate the results of the pain treatment. They also reported an increased satisfaction with their own nursing documentation. Although much remains to be done, it must be acknowledged that the 'pain-advisers', with relatively small resources, managed to make significant improvements.

Attitude of Health Personnel↗
PubMed2003

Experiences of using the VIPS-model for nursing documentation: a focus group study [corrected].

BACKGROUND: The present investigation is part of a study where the Registered Nurses on three hospital wards received a 2 year intervention programme on nursing documentation in accordance with a keyword structure based on the nursing process. AIM: To describe the Registered Nurses' perceptions of and attitudes towards the effects of the intervention, and to generate hypotheses for further research. METHOD: Focus group discussions were used to collect data, with a qualitative content analysis method for the processing of the data. FINDINGS: The most interesting finding in these group discussions was the statements made by participants that the structured way of documenting nursing care made them think more, and think in a different way about their work with their patients. Two types of role changing were reported; from a medical technical focus to a more nursing expertise orientation and from a "hands on clinician" to more of an administrator and secretary. CONCLUSION: A number of issues debated among the participants in this study could be seen as organizational matters and lead to the important issue of multidisciplinary and organizational work when implementing innovations within nursing.

Attitude of Health Personnel↗
PubMed1999

The wider implications of an audit of care plan documentation.

This article describes how the results of an audit of district nursing care plan documentation have been used to inform practice development in a community trust. The principle aim of the audit was to discover whether the evaluation of patient care was being adequately recorded in nursing care plans. To establish this, four commonly occurring areas of district nursing work were selected and an ideal assessment of care developed from the available evidence. The areas were: the management of leg ulceration, bath care, pressure area care and catheter care. Data capture forms were developed to record whether the features of an ideal assessment of these four areas of care were reflected in the written evaluation of that care. The results of the audit demonstrated that the evaluation of care was often inadequately recorded, which reflected poor written documentation of the initial nursing assessment. The implications of the findings of the audit for practice development in the four areas of care are discussed.

Documentation↗
PubMed2001

Developing a module for nursing documentation integrated in the electronic patient record.

Norway's regional teaching hospitals are working together on a project to develop an interdisciplinary electronic patient record (EPR). This paper presents the results of a project to develop nursing documentation as part of an integrated EPR to improve the quality and continuity of patient care. The project used a consensus process as a working norm. The most important result is that the five hospitals have agreed on a framework for nursing documentation, and on the main components that need to be implemented in the electronic patient record.

Computer User Training↗
PubMed2002

Documenting diabetes care: the diabetes nurse specialists' perspective.

Diabetes Nurse Specialists (DNSs) are often the hub of the communications network for the entire diabetes multiprofessional health care team, patients and their families. Frequently they liaise between primary and secondary care and have a key role in the provision of a 'seamless service'. To work effectively and efficiently they need a foolproof system of documentation and communication. The aim of the study was to investigate the means by which DNSs document patient care in order to provide baseline information about ongoing record-keeping practices. The study comprised a cross-sectional survey in which data were obtained by questionnaire. All DNSs in the UK registered with the British Diabetic Association were invited to participate in the study. A 70.3% response rate was achieved (n = 545). The results indicated that manual profession-specific records were used by 65.3% of DNSs, 21.1% used shared/integrated records, 12.8% used computerized records and only 0.7% made use of patient-held records. Whilst almost all DNSs felt that a good record-keeping system was essential in providing 'seamless care' to patients, not all felt their system was efficient. Of those using a computerized system 65.7% rated it as efficient, compared with only 28.1% of those using a profession-specific system and 26.1% of those using a manual shared system. A high percentage of DNSs (65.9%) felt that the provision of 'seamless care' was hindered by communication problems with members of other professional groups. The findings from this study indicate that computers alone cannot bridge the gap between primary and secondary care, but 'seamless care' may become more of a reality with computerized record-keeping systems and participation by all members of the multidisciplinary team.

Attitude of Health Personnel↗
PubMed2003

Medication trends and documentation of pain management following surgery.

The purpose of the present study was to examine prescribing and administering activities for sedative and analgesic medication in postoperative patients, and to describe nurses' documentation practices for pain management in nursing notes. A prospective audit was undertaken of medication order charts and nursing notes of 100 patients on the operation day and over the first four days following surgery. Almost all patients received some form of infusion, while the use of 'as required' analgesics varied from one-third to over two-thirds of patients during the postoperative period. Few patients were prescribed fixed-order analgesics or sedative medications. An audit of nursing entries found that nurses had documented inadequately in four major areas: pain assessment, use of non-pharmacological interventions, use of pharmacological interventions, and outcome of interventions. The findings contribute to improving our understanding of nurses' pain management and identify the need to use clinical judgement that is individualized to patients' needs.

Analgesia↗
PubMed1975

[RODOC--a system for the documentation of radiographic diagnoses with electronic data processing (author's transl)].

A system for the documentation of radiographic diagnoses is described, based on the "documentation method for radiographic diagnosis" (Formmhold et al 1972) and on the diagnostic information system of the medical faculty of the University of Tübingen. The diagnostic indeces are dictated in relation to the findings and the diagnosis and fed on punched cards into a computer (IBM 1800). Various programmes provide patient-orientated diagnoses for clinical routine, as well as diagnoses-orientated lists of patients for demonstrations, teaching or research.

Diagnosis, Computer-Assisted↗
PubMed2000

[Standards in information technology-assisted tumor documentation].

Data standards are a irrevocable pre-condition for a variety of applications in information technology, e.g. documentation, communication, and analysis. For this purpose, contents as well as rules for the representation of contents have to be defined. Tumour documentation has a long standing tradition. This contribution shows, which standards exist, how they are related to each other, what they are used for, and which tools exist.

Data Collection↗
PubMed2000

[New possibilities in the diagnosis and documentation using 3D power doppler ultrasound with carcinoma of the floor of the mouth as illustration].

AIM: To evaluate a novel 3D power Doppler ultrasound-technique (3D PDUS) in the diagnosis and documentation of tumours of the floor of the mouth. METHOD: 22 patients with tumours of the floor of the mouth (2 T1-, 5 T2-, 6 T3- and 9 T4-carcinomas) prospectively underwent conventional grey-scale ultrasound combined with power Doppler ultrasound and 3D PDUS (3-Scape). All examinations were performed with the "Sonoline Elegra Advanced" in combination with a 7.5 MHz transducer. Two independent observers compared the results regarding clear tumour margins, midline crossing, infiltration of the mylohyoid muscle, infrahyoidal tumour, contact to the mandible, contact to major vessels (such as the lingual, submental and/or facial artery), intra- and peritumoural vascularisation and judged the value of the 3D reconstruction method for documentation purpose. RESULTS: All parameters relevant for therapy could be gathered from the 3D data (agreement: 98.2%) almost without loss of information; results of both observers were identical (kappa value: 1.0). In the comparison to conventional ultrasound, 3D PDUS also allows for the reconstruction of axial images of the floor of the mouth similar to CT-images, and a 3D image of tumour vascularisation can be obtained. Acquisition and reconstruction of the 3D data only takes a couple of minutes. CONCLUSIONS: "3-Scape" is a novel easy-to-perform method allowing the complete acquisition of 3D data of the entire floor of the mouth, and providing the possibility to digitally store and/or transfer examination results without loss of information. Reconstruction of ultrasound-images in any desirable plane and/or as a 3D presentation is possible. Thus, in the future, additional software will facilitate the determination of the volume and the degree of vascularisation of tumours.

Adult↗
PubMed2001

[RecDate - an IT-solution for the documentation and quality management of reproductive medicine].

OBJECTIVES: The aim of this paper was to describe the possible use of the software RecDate für documentation and Quality Management in Reproductive Medicine. MATERIAL AND METHODS: RecDate was programmed using the data base program Filemaker Pro. The functions and potentials of RecDate were analyzed. RESULTS: RecDate enables the collection, documentation and evaluation of data from Reproductive Medicine and also functions as a hospital management tool. CONCLUSIONS: The present status of Reproductive Medicine can be described by the use of RecDate in IVF-clinics, which is important for consulting and treatment of couples, for the quality of public enlightenment and for optimizing the processes in daily routine.

Computer Communication Networks↗
PubMed2002

[Necessary prerequisites for the function of an oncological competence center. Information technology, documentation of findings and telecommunication].

INTRODUCTION: The organisation of an interdisciplinary cancer center, especially the establishment of a daily tumorboard requires adequate hardware and intelligent software, which is not available in most hospitals and described here with concepts, realisation and first clinical results. MATERIALS AND METHODS: Based on a TCP/IP network and several inhomogeneous department subsystems we developed an intranet-based oncological documentation- and conference software (oncofile), which can be easily operated and administered in a web browser. Common digital media can be imported and the concept allows for paperless organisation of the daily tumor board. The expert decisions are documented online during tumor board runtime together with selected clinical images and the consensus of the decisionmakers. Local therapeutic guidelines as well as trial information can be accessed over the intranet, and interfaces for internet- and telecommunication are used for second opinion and integration of external expertise. RESULTS: Between 10/99 and 2/2002 3298 presentations of 2438 cases were made in the daily tumor board. 74% of the patients had a curative oncological treatment concept, and 24% of the patients received neoadjuvant treatment. 49% of the patients were scheduled for primary resection. Six patients can be effectively handled in a 30 minute tumorboard. CONCLUSION: The establishment of a daily tumorboard is possible by help of intranet-technology, a central database with web clients and moderate hardware investments. The composition of the patient cohort as well as all decisions ever made to a particular patient are transparent at all times. Prospective quality control studies are under way.

Cancer Care Facilities↗
PubMed1994

[Acceptance of electronic data processing supported documentation of ultrasound findings in routine clinical practice. A survey].

We carried out a survey to determine the acceptance of the ultrasound documentation software, CUBUS, in clinical practice. Since August 1, 1988, CUBUS, versions V1.01 to V2.02 has been employed in clinical routine. By October 1991 10,850 reports had been stored in version 2.02. The software is installed on a personal computer (Siemens PCD-2, 40MB, 640 KB RAM) to which a laserprinter is connected. The work of operating the system is shared between the nursing and medical staff. In order to investigate the acceptance of the printed reports produced with this system, we carried out a poll among the physicians working at the hospital. Among the 86 physicians who receive 95% of the US reports, 58% (n = 50) responded. On the basis of the categories good, satisfactory, adequate and poor, we requested an assessment of layout, presentation, comprehension, completeness and overall impression. The overall impression was assessed as good or satisfactory in 34% and 42%, respectively. In the case of the individual criteria (see above), the categories good and satisfactory scored 62% and 34%, 58% and 32%, 68% and 18% and 72% and 24%, respectively. The terminology used was accepted by 84%. Addition of, for example, image documentation, and endosonography, will expand the advantages of the input of findings and further improve the good overall impression made by the report printout in our survey, so that the relatively long input time requirement accounting for some 30% of the total examination time, is accordingly justified.

Attitude of Health Personnel↗
PubMed1993

[Clinical documentation in obstetrics and collection of relevant data with reference to the structural reform law. Results of a survey of 72 clinics].

This study was conducted on the spread and usage of computer-aided software programme (GDS) in 72 obstetric departments. Standardised questionnaires were sent to universities and hospitals to ask for information on registered perinatal data. The record with the hand-written delivery book cannot record all data needed for quality protection as the PC is able to list. 89% of the obstetricians evaluate their clinical data regularly by statistical survey and classification. By analysing the general trend they can critically assess their actual obstetrical management. The PC is established in 83%, functions without technical problems in 92% and is optimal in the sequence of operation in 57% of all departments questioned. Overtime hours for the staff could be reduced in 11%, if a computer was used, and in 13% the nurses could take more care of mother and child because of less official red tape. Independent of the size of the department and the data processing knowledge of the staff, the software programme runs efficiently. The comprehensive basis data documentation with all perinatal and neonatal data is used to its full extent in 100% of the cases and documents the clinical effectivity. With regard to the standardised hospital quality control process by the modified requirements in the public health legislation, the directors of the hospital departments are able to assess the quality control and show economic independence.

Attitude of Health Personnel↗
PubMed1994

[The value of a new digital laser card for image/report documentation and transmission].

The capabilities of a patient-oriented digital optical laser-card for the documentation of the image/report unit and for image transmission were assessed. 150 conventional X-rays covering the fields of urology (n = 50), traumatology (n = 50) and orthopaedics (n = 50) were digitised using a CCD scanner and subsequently transmitted to an Image-Transfer Medium (ITM) and to an optical laser-card. The image quality for the detection of relevant diagnostic parameters was evaluated by 4 radiologists and one clinician of the corresponding specialty. Based upon a total of 4740 decision readings for each method, it was found that the optical laser-card reduced the image quality significantly (p < 0.01) in comparison to the digitised ITM images in all fields. Thus, a primary diagnostic statement cannot be made based upon the images of the optical card. However, concomitant documentation of the image and opinion on the card may be used for the transmission of the radiological report, especially to external referring institutions.

Documentation↗
PubMedDate not supplied

[Analysis and assurance of complete medical documentation].

A written report on the findings of the examination forms the basis for the further procedure in the treatment of a patient--not merely in the area of orthopaedics. The examination findings should, therefore, be legible, readily understandable and complete. On the basis of 600 individual findings established at admission in the case of inpatients with diseases of the spine and hip, stemming from a total of three hospitals, the behaviour pattern of the individual examiner is analysed along with deficiencies in documentation. For a number of significant deficits, differences in the particular emphasis applied by individual physicians during the examination, the fact that the time available for such examinations is usually limited, and the lack of documentation system, are probably responsible.

Data Collection↗
PubMedDate not supplied

[The reliability and sources of error in basic clinical documentation--a critical report of experiences].

Since 1. 1. 1985, computer-aided basic medical documentation has been routine at the University Orthopedic Clinic in Friedrichsheim, near Frankfurt. In addition to data on patient's histories, all data needed to satisfy the criteria of the Federal Directive on Operating Cost Rates are gathered. The diagnoses are stored in clear text, in a modified Eichler code, and according to ICD 9. Conversion from the Eichler code to ICD 9 is almost fully automated. In a study covering 100 hospitalized cases the following findings were obtained relating to sources of error and reliability: Without any additional in-house plausibility checks, the rate of error in the ID code, created by coding family name, date of birth, and sex, was 7%. In clear text all diagnoses except one and all forms of therapy were correctly reproduced as contained in the medical report. On the other hand, 7% of the conversions into the Eichler code contained errors. The reason for the difference in the quality of data is pointed out. In some of the other surveys, e.g., of infection rates, the rates of error were very high; most errors had been caused by the ward physicians. Data quality is enhanced by exploitation of routine process data when these control administrative procedures or are used for communication between physicians, since they then become relevant to actions and decisions and hence have to be reliable, regardless of documentation purposes.

Bone Diseases↗
PubMed2004

Evolution of document networks.

How does a network of documents grow without centralized control? This question is becoming crucial as we try to explain the emergent scale-free topology of the World Wide Web and use link analysis to identify important information resources. Existing models of growing information networks have focused on the structure of links but neglected the content of nodes. Here I show that the current models fail to reproduce a critical characteristic of information networks, namely the distribution of textual similarity among linked documents. I propose a more realistic model that generates links by using both popularity and content. This model yields remarkably accurate predictions of both degree and similarity distributions in networks of web pages and scientific literature.

Databases, Bibliographic↗
PubMed2004

Documentation of hip prostheses used in Norway: a critical review of the literature from 1996--2000.

We have conducted a systematic review of the scientific literature concerning outcome and clinical effectiveness of prostheses used for primary total hip replacement (THR) in Norway. The study is based on two Health Technology Assessment reports from the UK (Faulkner et al. 1998, Fitzpatrick et al. 1998), reviewing the literature from 1980 to 1995. Using a similar search strategy, we have evaluated the literature from 1996 through 2000. We included 129 scientific and medical publications which were assessed according to a specific appraisal protocol. The majority (72%) were observational studies, whereas only 9% were randomized studies. We could not retrieve any peer-reviewed documentation for one third of the implants. The Charnley prosthesis had by far the best and most comprehensive evidence base with better than 90% implant survival after about 10 years. Survival of the Charnley prosthesis declines by about 10% during each of the two following decades. Except for the Charnley and Lubinus IP, no other prosthesis on the market in Norway has given long-term results (> 15 years). 5 other cemented implants have given comparable results at about 10 years of follow-up. Some uncemented stems have shown promising medium-term outcome, but no combination of uncemented cup and stem fulfilled the benchmark criterion of > or = 90% implant survival at 10 years, which we propose as a minimum requirement for unrestricted clinical use for prostheses used in primary THR. New or undocumented implants should be introduced through a four-step model including preclinical testing, small series evaluated by radiosterometry, randomized clinical trial involving comparison with a well-documented prosthesis, and finally, surveillance of clinical use through registers.

Arthroplasty, Replacement, Hip↗