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At least 109 records · Page 6Linked to original sources
PubMed1985

[Value of cassette-recorded long-term 8-channel EEG monitoring--ambulatory recording in known epileptics].

The authors insist on the real improvement of ambulatory EEG recording due to the new 8-channel cassette recorder (Medilog 9000*). They emphasized: (1) its maniability with full independence of patients and physiological sleep recordings at home; (2) its viability, the same as conventional EEG with 8-channel montages; (3) its performant video-screen replay system, with easy paper transcription. The results in 50 ambulatory epileptic patients out of the 100 examinations actually realized in the EEG laboratory with this new device are detailed. Most interesting, in addition to sleep recording, is recognizing the number and the time repartition of paroxysmal discharges every 24 h; increasing the chances of recording randomly occurring seizures and the future chronobiological studies. The indications in epileptic seizures are myoclonic and 'temporal' epilepsies and also, with one channel for ECG recording, the diagnosis of attack of uncertain etiology.

Adolescent↗
PubMedDate not supplied

To record or not to record: documentation in clinical supervision.

Despite the continued interest of nurses in clinical supervision there remain many unanswered questions and unresolved issues. One such key issue is that of record keeping within clinical supervision. Consequently, this article reviews the limited literature that addresses this issue. It is evident that there are three principle discrete positions regarding recording in supervision and these are summarized as (1) the superviser records minimum data to meet the needs of audit (2) the supervisee makes extensive notes for his/her learning journal, reflective diary and (3) the superviser records headings or key words to be used as an aide-mèmoire. The article then uses three case studies to illustrate particular concerns that the trainee supervisees have raised with regard to record keeping that centre around these three positions, and discusses the issues that arise from these concerns. As a result of this discussion, the author reasons that, when entering supervision, either as a new superviser or as a supervisee, it may well be necessary and beneficial to give mind to issues of recording. While it is unlikely that there is one 'perfect way' that will suit every practitioner, the article concludes with some general guidelines whih may help in this deliberation.

Clinical Competence↗
PubMed1997

Direct brainstem recording of auditory evoked potentials during vestibular schwannoma resection: nuclear BAEP recording. Technical note and preliminary results.

The usefulness of intraoperative monitoring in cerebellopontine angle surgery should be improved by obtaining faster and stronger brainstem auditory evoked potential (BAEP) responses. A new technique of direct recording at the brainstem has been developed, which is applicable to all tumor sizes. By placing a retractor with electrodes attached to its tip at the cerebellomedullary junction, the authors have recorded BAEP amplitudes that are 10 times greater than those recorded using the conventional technique. Only small sampling numbers (64-256 recordings) are required and are obtained in 5 to 15 seconds. The technique has been applied successfully in 34 patients who underwent vestibular schwannoma resections. It has also been tested in patients with intrameatal-extrameatal meningiomas and in those with vascular compressive disorders; there have been no false results. The advantages of this new technique are: 1) identification of BAEP components is easier and faster; 2) reliable BAEP responses are obtained in some cases in which conventional BAEP responses are lost or severely deformed; and 3) BAEP response deterioration and improvement are recognized earlier than would occur using the conventional technique. This last advantage provides the surgeon with a useful warning at a stage of surgery at which BAEP changes are still temporary and can be reversed. This method is different from other trials of intradural BAEP recordings in three respects: its use is not limited to particular tumor sizes; there is no interference with the surgical process; and, most important, the obtained responses correlate well with those of conventional BAEP responses, probably because the recording site is in the vicinity of the anterior cochlear nucleus. In conclusion, the chances of useful monitoring feedback with adequate adaptation of the microsurgical strategy are improved considerably.

Cochlear Nerve↗
PubMed1983

Availability of information and records to the public; fees for providing information and records; procedures and appeals--SSA. Notice of proposed rulemaking.

The Social Security Administration (SSA) announces proposed changes in the fees it charges for providing records from its files and record related services. These proposed changes will conform SSA's fee schedule to that recently published by the Department of Health and Human Services (HHS). The proposed rules also implement the discretion given the Secretary of Health and Human Services by section 2207 of the Omnibus Budget Reconciliation Act of 1981 to charge the full cost of providing certain information and records. The proposed rules do not change SSA's longstanding policy of generally not charging an individual for information needed to assure that our records concerning her or him are correct. In preparing these amendments, we deleted from SSA's rules several provisions concerning Medicare information. The Health Care Financing Administration (HCFA) has published separate regulations governing the availability of Medicare information and records. We have also clarified the rules for handling requests for information about individuals under the Privacy Act and the Freedom of Information Act (FOIA) and incorporated HHS' recent rules on who has authority to release or deny records in this revised material.

Fee Schedules↗
PubMed2002

[Elimination of electrocardiogram artifacts from electroencephalogram records by using the simultaneously recorded electrocardiograph data].

We developed a simple method to eliminate electrocardiogram (ECG) artifacts from electroencephalogram (EEG) records by using simultaneously recorded ECG data. The raw EEG data, the real EEG data and the ECG data were regarded as multi-dimensional vectors Ea, Er and C, respectively. Also, the ECG data, with reduced amplitude whose coefficient was denoted as 'k', were assumed to be overlapped on the real EEG. These assumptions introduced the equations [Ea = Er + k.C], [Er.C = 0] and finally [k = Ea. C/C.C]. This calculation method was implemented by a Macintosh computer using data exported from digital EEG recordings (sampled at 200 Hz with 16-bit resolution). In several subjects, sampling intervals of 5 or 10 seconds for calculation succeeded in eliminating ECG artifacts. However, regardless of the sampling interval, this elimination condition was not always efficient in several other subjects, including a brain-dead patient. It was suggested that the ECG data used were insufficient for the calculation, because only one hand-to-hand reference was used for simultaneous recording, as usual. This one ECG reference was able to express only one ECG projection. Then two other hand-to-foot references of ECG were added to the recordings, and the elimination procedure was performed using all of the simultaneously recorded ECG data at the three references. Consequently, elimination was much improved in most subjects, including the brain-dead patient. Our method may be useful for eliminating ECG artifacts without changing reference electrodes.

Artifacts↗
PubMed1991

Short-term sleep EEG recordings after partial sleep deprivation as a routine procedure in order to uncover epileptic phenomena: an evaluation of 719 EEG recordings.

All night sleep deprivation prior to an EEG registration causes some inconvenience not only to the organization of the EEG department but presents a burden on the patients as well as their family members, and for these reasons is not suitable to be frequently employed as a routine procedure. As an alternative, we performed short-term sleep recordings in the early afternoon following a partial sleep deprivation of the patients during the preceding night. This method was well accepted by the patients and their family. Our only goal was to shorten the total time of night sleep using the following guideline: for very small children 22.00-06.00; for 4-14-year-old patients 24.00-06.00; and for patients older than that 01.00-06.00. 79.9%, out of 719 patients (573) who had been given the above instructions subsequently showed sleep patterns in their EEG. Additionally we had to administer an oral dose of promazine to only 67 patients. However, for the most part, patients showed only light sleep stages: 114 patients only reached sleep stage 1; 323 patients sleep stage 2; 88 patients sleep stage 3; and 48 patients sleep stage 4. As expected, REM sleep was never recorded. Nonetheless, in 32 out of 146 patients who were tired but unable to fall asleep, epileptic patterns could be provoked. In 636 patients, the EEG-recording after sleep reduction was ordered because of a suspected seizure disorder; in the remaining patients it was initiated solely because of sharp components in the routine-EEG. In 341 (53.6%) of the patients with suspected epilepsy, electroencephalographic activity indicative of a seizure disorder was activated. Such epileptic patterns were recorded almost exclusively in stages of waking, 1 and 2. Only in one out of the 124 patients who reached sleep stages 3 and 4 epileptic patterns were not seen until deep sleep was entered. We observed 2/s, 3/s and 6/s spike-and-wave complexes, sharp waves, spikes, polyspikes, groups containing remarkably sharp components and so called sharp vertex grapho-elements. Patients with suspected seizure disorders frequently show grapho-elements which can be interpreted as the expression of a disposition for epilepsy. These sharp vertex elements were evident in 54 out of 719 short term sleep recordings, more often in children than in adults. 49 times they coincided with typical epileptic discharges such as sharp waves, spikes or spike-and-waves in the same recording.

Adolescent↗
PubMed1981

The Case Record Rating Scale: a method for rating symptom and social function data from case records.

Case records provide a vast resource of information for clinical research, yet their value has been limited by several methodological problems. One of these has been the absence of standardized approaches for making diagnoses and other clinical judgments from case record data. This report describes the Case Record Rating Scale, an instrument designed to provide a standardized method for abstracting case record information. The reliability of the scale is demonstrated, and the advantages and problems encountered using case record data for research are described.

Humans↗
PubMed1995

An analysis of the paper-based health record: information content and its implications for electronic patient records.

An analysis of paper-based charting was carried out at Sunnybrook Health Sciences Center as a prelude to developing a strategic plan to implement an electronic patient record. A relational model of the Sunnybrook paper chart was developed, describing each of its forms in terms of specific data fields. Three hundred and forty nine different forms are in current use at Sunnybrook, containing 64 types of data fields such as Patient Demographics, Vital Signs, and Doctor's Orders. The extent of data field duplication at the level of hospital forms was significant. A Patient Demographics field was present on all forms and on all pages of a patient's chart, as would be expected. Twenty seven other fields were duplicated on more than ten different forms, including Working Diagnosis which was present on 110 forms, History of Past Illness on 42 forms, and History of Present Illness on 32 forms. Current Medications were recorded on 32 forms and Allergy fields were present on 29 separate forms. Only five data fields of the total 64 were present on only one form. The duplication of data fields within complete patient charts was then examined to confirm that data field duplication was occurring within the actual healthcare delivery process. Using the relational model of the charting system, 143 acute care in-patient encounters were abstracted into the database. The charts were selected randomly from each of the hospital inpatient services. The numbers and types of forms within each chart were recorded, amounting to 18,654 physical pages and using 165 of the different forms. The average in-patient encounter within the model was 130.4 pages long, with a minimum of 27 pages, a maximum of 559 pages, and containing on average 25.8 different forms. The duplication of data fields within actual charts followed a pattern similar to the duplication found on the forms. Initial diagnosis was present on an average of 20.4 pages within the charts, with a minimum of 2 pages and a maximum of 152 pages containing this data field. Other frequently occurring data fields included History of Past Illness present on an average of 12.2 pages per chart, History of present illness on 10.2 pages per chart, and allergies on an average of 9.1 pages per chart. The results obtained through the examination of Sunnybrook charts should be generalizable to most paper-based systems. This study did not measure the workload associated with duplicating chart data. however, the magnitude of the duplication seen in this study leaves little doubt that significant amounts of time could be saved with appropriate modification of health care delivery processes. Multiple copies of the same data field within a database are referred to as aliases of each other. This study demonstrates that hospital charts contain many copies of the same information, such as medication lists, allergies etc. Due to manual replication of data fields, there is no mechanism to ensure that each copy of a data element within a chart actually contains the same information. This aliasing of data through manual duplication compromises the integrity of data within paper-based charts. Decisions and therapy based upon contradictory or inaccurate data are likely to lead to inefficient or erroneous care delivery; this has significant implications for hospital liability and quality of patient care. A growing recognition of the costs and risks of data replication within paper-based charting systems is driving the healthcare industry toward Electronic Patient Record systems. Better quality patient care data, provided by computerized records, is likely to be necessary but not sufficient to improving the efficiency and effectiveness of the healthcare system. Intelligent application of this information will be essential.

Medical Records↗
PubMed1992

A simple electronic device for time-lapse recording of neural and other cell movements using a home video cassette recorder.

This article describes a simple electronic unit to obtain time-lapse recordings with the use of a common remote-controlled home video cassette recorder, for example a VHS recorder. The electronic unit is a timer to be connected to the remote-control unit. The video cassette recorder itself remains unchanged. Replay of the recorded images speeds up the original process by a factor of 2-100 x or more. This technique has been applied in video micrographic studies of (1) the development of dorsal root ganglion (DRG) cells in culture, including growth cone and Schwann cell movements, and (2) tumor cell killing by natural killer (NK) cells.

Animals↗
PubMed1994

Structuring the patient record: NUCLEUS (customisation environment for multi-media integrated patient records).

The NUCLEUS project (AIM A2025) develops a prototype of a multi-media integrated patient record, based on the concepts of intelligent act management as conceived in RICHE (Esprit 2221). Moreover, NUCLEUS creates facilities for the customisation of such patient record according to the requirements of the health professionals (physicians, nurses, therapists, etc.) who operate and consult the patient record. Health professionals retain full control of the patient record contents:--NUCLEUS offers facilities to structure any significant patient record, subject to the specifications of the health professionals involved. Finally, NUCLEUS implements its results in the practical clinical conditions of the three leading European hospitals.

Europe↗
PubMed1994

Completeness of prescription recording in outpatient medical records from a health maintenance organization.

Since validity of drug data is often characterized by the agreement between questionnaire and medical record data, medical record completeness for drug therapy was evaluated. Outpatient medical records of 501 randomly selected Group Health Cooperative Health Maintenance Organization (HMO) participants known to have been dispensed a non-steroidal anti-inflammatory drug (NSAID) were reviewed for completeness. Documentation was also evaluated for indication, age, gender, location of visit, and number of visits. The NSAID was recorded in 89% of the charts reviewed. Charts with a vague/missing diagnosis were more likely to lack documentation [RR (95% CI): 20.0 (13.2-30.3)]. The data suggested that poorer documentation was related to older age [1.5 (0.9-2.5)] but not to gender, indication, location of visit, or number of visits. Presence of an indication was positively correlated to the completeness of drug documentation. According to this staff/group HMO, there may be a higher concordance between self-reported medication use and medical record data than found in previous literature.

Age Factors↗
PubMed2004

[Quality dimensions in patient records--a standardised analysis of nursing home resident records].

279 resident records of 26 nursing homes were analysed using a standardised instrument as part of a comprehensive study about the quality of nursing homes in Frankfurt on Main. The main questions referred to the completeness of several content indicators and the visibility of the nursing process in the different parts of the records. Selection criteria were records only of residents in care dependency level two or three. From each of the 26 participating nursing homes at least 10 up to a maximum of 14 records depending on the number of residents were chosen. The best part of the documentation is the assessment, especially the body-oriented problems and resources and the caring devices. However neither the resident's perspective or the source of information are generally noted. The planning part contains mainly interventions, is not always related to the assessment and refers quite seldom to the support of resources. The report shows even more deficiencies. The worst part is the evaluation. A comparison of extreme groups of nursing homes with a very good resident/staff relationship to those with a very bad resident/staff relationship shows that many parts of the records, but not all, are much better documented in the homes with more staff than in those with less staff.

Aged↗
PubMed2003

Methods to study pre-school teachers' voice at work: simultaneous recordings with a voice accumulator and a DAT recorder.

Long-term recordings with reliable methods are desirable for objective documentation of voice use during natural conditions. The purpose of this study was to evaluate a voice accumulator (VAC) with a digital audiotape (DAT) recorder as a reference. The VAC is based on a microprocessor that accumulates information about fundamental frequency (F0) and phonation time. A contact microphone attached to the front of the neck registers vocal fold vibrations. The DAT recorder was connected to two microphones for airborne signals placed at equal distance from the mouth close to the subject's ears. The computer program Aura was used to separate the subject's voice from the background noise. The Soundswell program was used for F0 and phonation time analysis. Two tests were performed: 1) One female speech-language pathologist was recorded with the two devices simultaneously in a sound-proof booth. She read a standard text with different voice qualities and sustained vowels with increasing F0 and intensity separately. The results showed good agreement between the two methods with respect to F0 and phonation time. However, the VAC failed to register high frequencies above around 440 Hz as well as low intensities. 2) Three female pre-school teachers were recorded with the two devices simultaneously during a working day. Results showed high correlations between the two methods in terms of long-term measurements of F0 and phonation time for two subjects For one subject with subcutaneous soft tissue on the neck, the registration with the contact microphone was not reliable. It was concluded that the VAC has potential for assessment of occupational voice disorders if certain limitations of the method are considered.

Equipment Design↗
PubMed2003

Generating information from electronic patient records in general practice: a description of clinical care and gender inequalities in coronary heart disease using data from over two million patient records.

OBJECTIVES: To describe the epidemiology of coronary heart disease (CHD) in England and the activity of primary healthcare teams in managing patients with CHD, and also to demonstrate the utility of computerised patient records in providing access to epidemiological data and data reflecting healthcare activity. DESIGN: A descriptive survey of CHD and related clinical data, recorded using computerised clinical records, entered by primary healthcare teams. Aspects reported include prevalence of CHD, together with additional data reflecting clinical monitoring activity, therapeutic interventions and comorbidity in patients affected by CHD. SETTING: 317 general practices in 23 English primary care trusts (PCTs). DATA ACQUISITION: MIQUEST was used to interrogate 2 252 274 computerised patient records. Data were extracted in the form of sex and age aggregated counts of patients meeting a range of extraction criteria. RESULTS: The observed crude prevalence of CHD is 40.3 per 1000 (males 46.6, females 34.2). A variety of findings are presented relating to the treatment, monitoring and comorbidities of CHD. Significant and systematic gender inequalities are demonstrated to exist in the monitoring and treatment of CHD. CONCLUSIONS: Extraction of data from computerised patient records is a valuable and practicable method of generating information to inform clinicians and National Health Service (NHS) organisations. Systematic gender disparities exist in the care delivered to patients with CHD.

Coronary Disease↗
PubMed1983

Privacy Act of 1974; system of records--PHS. Waiver of advance notice period for a new system of records.

FR Doc. 83-18581, appearing at page 31738 in the issue of Monday, July 11, 1983, provided notification of a new system of records proposed by the Health Resources and Services Administration (HRSA). That system is 09-15-0045, "Health Resources and Services Administration Loan Repayment/Debt Management Records System, HHS/HRSA/OA." The document stated that the Public Health Service had requested that the Office of Management and Budget (OMB) grant a waiver of the usual requirement that a system of records not be put into effect until 60 days after the report is sent to OMB and the Congress OMB granted the requested waiver on August 3, 1983. Accordingly, the new system of records, 09-15-0045, became effective upon the date of the waiver except for the routine uses established for the system. They became effective August 11, 1983, following the public comment period. However, in response to a comment received from the responsible oversight committee of the U.S. House of Representatives, we are adding a routine use to permit disclosure of information from these records to the General Accounting Office (GAO) and OMB for auditing financial obligations. We are also modifying one of the existing routine uses. PHS invites interested parties to submit comments on the proposed new routine use on or before September 29, 1983. In accordance with the Debt Collection Act of 1982 (Pub. L. 97-365), we are also adding the "special disclosure" statement. This statement does not require a public comment period.

Records↗
PubMed1984

The American Psychiatric Association's model law on confidentiality of health and social service records: allowing patients to examine and correct their mental health records.

Traditionally, mental patients have been denied access to their own mental health records, even though third parties such as insurance companies, prospective employers, and government agencies have access to the records and use them in deciding whether to grant benefits or employment to the patients. Adoption of the American Psychiatric Association's Model Law on Confidentiality of Health and Social Services Records would end this anomaly by allowing patients to examine their own records. This article examines the problems that arise from the inaccessibility to patients of their records and the present inability of the law to remedy these problems. It then summarizes the major access provisions of the Model Law, suggests ways it can be improved to further protect patient interests, and sets forth the probable clinical benefits that will result from access.

Confidentiality↗
PubMed1995

[The medical record--content, interpretation and quality. Study of 100 medical records from a department of internal medicine].

An evaluation of the primary medical records of 100 patients admitted to a medical department showed that several elements in the journal often had been left out. Therefore all doctors working in the department were asked for their opinion of the necessity for each of the elements in a journal. A comparison of these doctors' opinions with our registrations indicated that the actual "shortening" of the journals was probably a result of choice rather than mere chance. Despite a considerable amount of work trying to establish relevant criteria, we did not succeed in developing a reliable method for measuring the quality of the medical record. The journals recorded at night were significantly shorter than those recorded during the day. A follow-up note (or discharge of the patient within one day), was found in 80% of the journals. Quality standards of the medical record are lacking and should be developed.

Evaluation Studies as Topic↗
PubMedDate not supplied

Correlation of dental-record medical histories with outpatient medical records.

Medical history questionnaires and outpatient medical records of 115 patients were compared. All patients had a medical history of at least two years in both records. The dental records were initially reviewed, and patients' responses were compiled; when these were compared with the outpatient medical records, the overall discrepancy rate was > 86 percent. This overwhelming rate of error should make dentists aware that many routinely treated patients have medical conditions that are unknown to providers. Use of universal precautions, adequate medical-emergency training, and oral review of the dental health questionnaire are recommended.

Adult↗