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At least 1,081 records · Page 60Linked to original sources
PubMed1995

General practice medical records: is coding appropriate?.

Codes in general practice have been used for some time to facilitate medical research and for the gathering of health statistics. Coding is used to standardize terminology and avoid ambiguity. In general practice, this coding has usually been done some time after the notes are recorded and often by a person not involved in the consultation. This has been necessary because most medical records are recorded on paper using natural language. Does coding have any place with the individual general practitioner (GP) if health statistics or medical research are not involved? General practice notes are extremely variable; they are a collection of free form text, diagrams, idiosyncratic, and standard abbreviations and are usually stored on paper and often include several summary pages. This type of record does not easily lend itself to coding. With the increasing use of computers, the electronic record will become more common and may eventually replace the paper record [1]. As this occurs, the possibility of universal coding will increase, and there may be some pressure for all GPs to record their notes in a standard format and/or use standard codes.

Diagnosis↗
PubMedDate not supplied

[The use of nursing records in the Veneto region].

Use and quality of nursing records used in the Regione Veneto hospitals was evaluated. An open ended questionnaire was sent to the nurses managers of each hospital. The questionnaire asked some general information on the hospital (number of beds, number and qualification of nursing personnel) and nurses managers were asked to send a blank copy of the nursing records in use. 21 nurses managers answered, overall responsible for 28 hospitals. Nurses records are used in 78 wards over 412 (19.1%). The wards are different for specialty and characteristics. Apparently, the only factor associated with the implementation of nursing records is the number of beds, with a wider implementation of nursing records in smaller hospitals. No association was found with the level of qualification of the nursing personnel. 11 nursing records were received. The items to be compulsorily monitored were mostly physical needs (i.e. elimination, hygiene, nutrition, mobilization), with the exception of the two records used in the psychiatric wards, where data on the behaviour and reaction of the patient was available.

Forms and Records Control↗
PubMed1998

Evidence-based well-baby care. Part 2: Education and advice section of the next generation of the Rourke Baby Record.

PROBLEM BEING ADDRESSED: Well baby and child care in the primary care setting has not always been based on evidence that has been shown to be effective in preventing and detecting disease and injury. OBJECTIVE OF THE PROGRAM: To help physicians and nurses provide care that is more effective than a routine complete examination, the Rourke Baby Record has been revised to include evidence-based recommendations for preventive care for infants and young children. The revision incorporates the approach and recommendations of the Canadian Task Force on the Periodic Health Examination. The updated record is now called the Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance Guide (Rourke Baby Record: EB). MAIN COMPONENT OF PROGRAM: Part 2 of this two-part article discusses the maneuvers included in the education and advice section of the record. These maneuvers are discussed under the subheadings safety, behaviour, family coping, high-risk children, and other. CONCLUSION: Using the Rourke Baby Record: EB and incorporating it into their office record systems as a working guide will help increase the effectiveness of the primary preventive care physicians provide to infants and young children.

Child↗
PubMed1992

"Shuttle sheet": a patient-held medical record for pediatric oncology families.

A patient-held medical record used by a pediatric oncology unit is described. Each patient's family is provided with a folder containing detailed information about the patient's current treatment. The record helps orient all health care workers involved in the patient's management to the treatment schedule, including exact doses of drugs. Details of blood counts and treatment given are entered by health care workers at each consultation, but the record is always retained by the family. The benefits of this record are that it saves time, reduces the likelihood of errors in scheduling and doses of cytotoxic drugs, and facilitates continuation of therapy at locations away from the supervising oncology unit. It reduces the amount of correspondence required for patient care, is a useful diary and treatment planner for the patient's family and hospital staff, and is an educational resource for the patient's family. It is a useful adjunct to the hospital's medical record for clinical trial data, is easily replaced if lost, and is inexpensive. It also assists surveillance of long-term survivors. The record is particularly valuable when used with patients who are being treated or assessed at more than one institution or by multiple health care workers. The record is in its 12th year of service and is used by more than 95% of patients on therapy attending the unit.

Australia↗
PubMed1995

Quality evaluation of 10 years patient records in forensic odontology.

In forensic odontology, accurate detailed and complete recording of ante-mortem information is essential as the basis for odontological identification. Earlier studies on malpractice cases in Sweden indicated that the quality of the recording procedure was not always acceptable. Therefore, the aim of this retrospective study was to investigate the quality of ante-mortem records and its possible implications for identification work. All forensic odontology cases referred to the Department of Forensic Medicine in Göteborg between 1983 and 1992 were studied with regard to the instructions for dental records from the National Board of Health and Welfare. Information on dental characteristics, normal anatomical findings and restorative treatment was complete in 43 (68%) of the cases, incomplete in 17 (27%) and missing in 3 (5%). Registration of previous therapy was missing in about 75 (94%) of the records. It was possible to identify patient radiographs in only 16 of the 40 records where radiographs were available. In spite of this, the inaccuracies in the records did not seem to hamper the identification procedures in this study which could be explained by the character of the cases and the availability of medical and circumstantial information.

Dental Materials↗
PubMed1995

Manual record keeping is not necessary for anesthesia vigilance.

OBJECTIVE: The goal of this study was to determine whether the intraoperative vigilance of anesthesia residents is different when they keep a manual record than when an assistant performs the charting. METHODS: A total of 9 anesthesia residents were studied during 36 general anesthesia cases on ASA class 1 or 2 patients. In half of the cases, the resident performed all record keeping. In the other half, the anesthesia record was kept by a human assistant. Vigilance was measured as detection rate and response time for the resident to detect a simulated abnormal value displayed on the physiologic monitor. For analysis, anesthesia cases were divided into stages of induction, maintenance, and emergence. RESULTS: Response times and detection rates were not different when record keeping was performed by an assistant, rather than by the clinician. Shorter cases were associated with longer median response times (i.e., lower vigilance) during the maintenance phase, but only when record keeping was done manually. CONCLUSIONS: The results demonstrate that anesthesia residents are equally attentive to an experimental signal displayed on an electronic monitor while manually charting as they are when an assistant keeps the record. This brings into question the contention that eliminating the record-keeping task will result in a reduced level of vigilance.

Ambulatory Surgical Procedures↗
PubMed1996

Use of data from a hospital online medical records system by physicians during preanesthetic evaluation.

OBJECTIVE: There is no data on the use of hospital-wide online medical record (OLMR) systems by anesthesiologists. We measured how often anesthesiologists accessed the OLMR database maintained by the hospital, how often data was copied from this database into the clinic's computer system, and how much data was copied. METHODS: In a preanesthetic evaluation clinic that has a computerized evaluation system designed for physician-entered data, a graphical user-interface prototype link provided access to the hospital OLMR database for users and was studied over a 37-day period. The software allowed the user to search the OLMR system by patient name, retrieve a text listing of the patient's record, and then copy and paste desired information into the forms of the preanesthetic system. Using embedded routines, we recorded how many times physicians searched for and retrieved medical records from the hospital OLMR database, as well as how many times they copied data to the preoperative database. As a measure of how much data was copied, the number of characters was also recorded. RESULTS: Of 1,080 patients evaluated in the clinic during the study period, electronic searches of the hospital OLMR database for 221 patients (20.5%) were noted. Of these searches, 208 (94.1%, or 19.3% of 1,080 patients) successfully retrieved data from the patient's record. Data was copied for 170 patients - 81.7% of the successful searches. Of 7,525,153 characters retrieved, 262,269 were copied-an average of 1,543 characters per instance of copying. CONCLUSION: We conclude that anesthesiologists, given even crude graphical access to a hospital OLMR data-base, will retrieve and copy data, potentially increasing the accuracy of the medical records and saving time.

Anesthesiology↗
PubMed1984

Improving the record-keeping performance of direct service personnel.

Record review procedures and contingent performance feedback were used to monitor and improve the record-keeping performance of human service staff in a behavioral residential treatment setting. A multiple baseline design was employed across three groups of B.A.-level human service personnel. The study consisted of five conditions: (1) Baseline 1; (2) Written Instructions (memoranda); (3) Written Performance Feedback; (4) Verbal Performance Feedback; and (5) Baseline 2 (return to the Baseline 1 condition). Dependent measures included highly reliable ratings by independent observers of the (1) essential documents present in case records, (2) documents approximately located/organized in case records, and (3) an overall rating of documents present, correctly organized, signed and dated, and not duplicated in the records. Results indicated that the procedures most frequently used to provide feedback to human services personnel--meetings, policy and procedure manuals, and/or written memoranda--were not as effective as verbal feedback sessions in prompting staff participation in case record maintenance. Findings were interpreted to suggest that, with adequate training, supervision, and performance appraisal, direct service personnel in residential treatment settings can effectively manage clients' case records and become more involved in, and committed to, accountability and quality control.

Employee Performance Appraisal↗
PubMed1987

The clinical use of the Ohmeda Automated Anesthesia Record Keeper integrated in the Modulus II Anesthesia System. A preliminary report.

While performing his complex array of tasks, the anesthesiologist is also responsible for maintaining an anesthetic record. Up to now, this has been done by hand. The clinical use of automated anesthesia record keeping is presently evaluated. The anesthesia records generated by the Ohmeda Automated Anesthesia Record Keeper integrated in the Modulus II Anesthesia System is compared to hand written records. The differences between the two records of identical patients are quantified as erroneous or missing data. With the criteria adapted, we found significant and clinically relevant differences which stress the importance of automated record keeping.

Anesthesiology↗
PubMed1998

What do doctors record in the medical notes following discussion with the parents of sick premature infants?

UNLABELLED: In a retrospective review of medical notes we determined: (1) how often doctors record discussions with the parents of very low birth weight (VLBW) infants during the neonatal period; (2) what details of any discussion they actually record and; (3) if they are more likely to record discussion with the parents of sicker infants. A random sample (30%) of all VLBW infants admitted between 1989 and 1993 to a regional NICU was reviewed, n = 87. No discussion was documented in 47 cases, one of whom died, 24 had a single episode of discussion recorded and 16 had two or more episodes recorded. Specific discussion about prognosis was only recorded in the notes of 27 babies. Discussion was more likely to be documented in sicker infants as measured by CRIB (clinical risk index for babies) score, t = -3.9, P < 0.001. CONCLUSION: A record of discussion between medical staff and parents is found in the medical notes of less than half of all VLBW infants. These findings may have practical, ethical and legal implications.

Ethics, Medical↗
PubMed2005

Linking birth and infant death records with assisted reproductive technology data: Massachusetts, 1997-1998.

OBJECTIVES: To link data from the US assisted reproductive technology (ART) registry with the Massachusetts birth-infant death file to create a comprehensive dataset on the circumstances surrounding conception and maternal and infant outcomes for a population of ART-conceived infants. METHODS: The authors sought to link data for 3704 ART-conceived live-born infants from 2703 deliveries in 1997-1998 involving Massachusetts resident mothers who gave birth in Massachusetts, Rhode Island, New Hampshire, or Connecticut to their corresponding Massachusetts birth record using a two-stage algorithm. Maternal and infant dates of birth served as the primary linkage variables. Maternal names for a subset of the ART-conceived infants were obtained and used in the second stage of the algorithm to confirm a sample of records that matched in Stage I, to resolve duplicate matches, and to link unmatched records. RESULTS: In Stage I, 78% of ART deliveries matched with only one Massachusetts record, 2% matched with two records, and 20% remained unmatched. Overall, the complete algorithm using maternal name data for a portion of records yielded an 89% linkage rate. Nearly all of the records that matched during Stage I that were evaluated with maternal name data in Stage II were confirmed as correctly linked. CONCLUSIONS: This project confirms that high-yield data linkage can be achieved in the absence of specific identifiers (e.g., name and social security number). Nonetheless, additional matches were achieved when name data were obtained. This linkage creates the first population-based file in the US capturing detailed information on ART births.

Algorithms↗
PubMed1990

Conducting a matched-pairs historical cohort study with a computer-based ambulatory medical record system.

We describe techniques for using the Computer-Stored Ambulatory Record (COSTAR) at the Massachusetts General Hospital to conduct a historical cohort study of the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on blood pressure control. A query language was used to identify patients satisfying clinical and data-availability criteria, to match these patients with clinically similar patients not exposed to NSAIDs, and to collect data from the COSTAR records of both groups of patients to determine any differences in outcome. We analyzed over 30,000 patient records to select 90 pairs of patients used in the study. This approach to clinical research uses data collected for purpose of patient care and so does not require the separate recording of patient data for clinical research. Using computer-based medical record systems with a query language allows selection and matching of patients using detailed demographic and clinical criteria. The ability to conduct such studies is an advantage of computer-based medical record systems over the paper record system.

Ambulatory Care↗
PubMed1981

A preextraction profile record.

The preextraction profile record is a means of easily, quickly, and inexpensively recording clinical data prior to extraction of the natural teeth. The record contains a great deal of preextraction information and can be easily stored in the patient's chart. However, the preextraction profile record does not obviate the need for other preextraction records such as radiographs, photographs, and diagnostic casts. The information recorded in preextraction records allows the dentist to have access to and compensate for the progressive changes which occur when the natural teeth are extracted.

Cephalometry↗
PubMed1993

Development of an accurate portable recording peak-flow meter for the diagnosis of asthma.

This article describes the systematic design of an electronic recording peak expiratory flow (PEF) meter to provide accurate data for the diagnosis of occupational asthma. Traditional diagnosis of asthma relies on accurate data of PEF tests performed by the patients in their own homes and places of work. Unfortunately there are high error rates in data produced and recorded by the patient, most of these are transcription errors and some patients falsify their records. The PEF measurement itself is not effort independent, the data produced depending on the way in which the patient performs the test. Patients are taught how to perform the test giving maximal effort to the expiration being measured. If the measurement is performed incorrectly then errors will occur. Accurate data can be produced if an electronically recording PEF instrument is developed, thus freeing the patient from the task of recording the test data. It should also be capable of determining whether the PEF measurement has been correctly performed. A requirement specification for a recording PEF meter was produced. A commercially available electronic PEF meter was modified to provide the functions required for accurate serial recording of the measurements produced by the patients. This is now being used in three hospitals in the West Midlands for investigations into the diagnosis of occupational asthma. In investigating current methods of measuring PEF and other pulmonary quantities a greater understanding was obtained of the limitations of current methods of measurement, and quantities being measured.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma↗
PubMedDate not supplied

"What did you say?" Using review of tape-recorded interactions to increase social acknowledgments by trainees in a community-based vocational program.

Dana and Rick, two adults with developmental disabilities enrolled in a restaurant training program, had poor prospects for long-term employment because of inappropriate social behavior. They often made no response, mumbled inaudibly, or made a negative remark when spoken to by their supervisors or other employees. Each trainee's Individual Vocational Plan (IVP) included goals of prompt and polite acknowledgement of coworker initiations. Previous efforts to improve Dana and Rick's acknowledging behavior had been unsuccessful. Throughout the study, each trainee's responses to 20 verbal initiations by coworkers (i.e., requests, questions, corrective feedback, praise, and social comments) were recorded during each of two observation periods per workshift. Throughout one of the observation periods during the intervention phases, the trainees carried in their work aprons a small, audio cassette recorder that recorded their interactions with coworkers. The primary intervention consisted of a preworkshift meeting in which the trainee and experimenter reviewed five randomly selected interactions recorded during the previous day's shift. The review included self-evaluation, praise, corrective feedback, and role-play. A multiple baseline across subjects design showed each trainee acknowledged a greater number of coworker initiations as a function of the intervention. Each trainee also acknowledged more coworker initiations during the second observation period when the tape recorder was never worn. In a subsequent intervention phase, Dana reviewed her tape-recorded interactions prior to randomly selected shifts. Rick's acknowledgments increased to a socially valid level when the review procedure was supplemented with graphic feedback. Both trainees continued to acknowledge their coworkers' initiations at levels equal to nondisabled restaurant employees when they no longer wore the tape recorder during a final phase and during follow-up observations 4 to 8 weeks later.

Adult↗
PubMed1996

Precision and estimated accuracy of two short-term food frequency questionnaires compared with recalls and records.

Two widely used food frequency questionnaires (Block FFQ, Willett FFQ) were modified to reflect intake over the past 7 days and compared to intake information gathered from diet records and 24-hr recalls covering the same 7-day period. The Block FFQ and the Willett FFQ were also gathered at the beginning of the assessment period to reflect the 7-day period of time before records and recalls were gathered. Fifty-six subjects were assigned to either recording diet for 3 days, recording diet for 6 days, or providing three 24-hr recalls. Results indicate similar levels of within-method test-retest reliabilities for 3-day RECORDS and 6-day RECORDS, and within the two Block FFQs and within the two Willett FFQs from each subject, while lower reliabilities were seen in 24-hr RECALLS. When the FFQs were compared to the 6-day RECORDS with between-method agreement coefficients, there was a moderate level of agreement, with most values between 0.5 and 0.8 for both FFQs. Significant differences between mean levels of nutrients estimated by the three methods indicated differences only in the estimates of carbohydrate and vitamin A. The use of FFQs to gather short-term intake information is discussed.

Adult↗
PubMed2004

[Quality-assessment of the transfusion record in a Paris hospital in 2003].

AIM OF THE STUDY: To realize a clinical audit of the quality of the transfusion record in the Pitie-Salpetriere hospital (Paris, France). MATERIALS AND METHODS: Using a 1/10th poll method, a representative sample of patients who underwent a blood transfusion in the first quarter of 2002 in the hospital was constituted. Data were collected in the clinical units using a standardized questionnaire. RESULTS: Sample size was 247 patients for whom 219 patient files and 207 transfusion record (94.5%, CI(95%) [91.5-97.5]) were found. Transfusion record did not follow the patient in 29 cases (59%). Among the transfusion record, 82.1% contained a copy of the prescription for blood components, 89.8% a transfusion card, 93.2% a traceability note, 100% an ABO group card, 98.6% an antibody screen, 57.1% a pretransfusion viral testing results and 7,8% a copy of the posttransfusion biology testing. Traceability of pre and posttransfusion patient information was respectively 6,8% and 21,1%. Presence of pretransfusion testing results, patient information and posttransfusion prescription was significantly higher in the surgical and intensive care units' patient files than in the medical units (resp. P = 0.018; 0.02 and 0.017). CONCLUSION: Difficulties in the transmission of transfusion records when patients change clinical unit or are rehospitalized and a lack of knowledge concerning the elements which are mandatory to be kept in the transfusion record could explain the results of this study. This assessment is fully in line with the process of transfusion security improvement. In order to promote the quality of the transfusion record, new recommendations and tools were elaborated following this study.

ABO Blood-Group System↗
PubMed2004

Digital video recording of cardiac surgical procedures.

PURPOSE: We attempted to find a method of reducing time and effort for recording videos of cardiac surgical procedures. DESCRIPTION: A camera mounting arm designed by us provided a properly fixed digital camera location for undisturbed recording. The camera and its remote control unit provided an opportunity for the surgeon to record only the steps of the operation without need for editing. EVALUATION: Digital videos produced by this method required no additional time from the surgeon except to record the commentary at leisure. The video recorded was of excellent quality and provided a well-focused recording of the steps of the operation. CONCLUSIONS: The technique described for video recording of cardiac surgical procedures provides a time-saving and easy method for good reproduction of surgical procedures.

Cardiac Surgical Procedures↗