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PubMed2003

DICOM structured report document type definition.

The Digital Imaging and Communications in Medicine (DICOM) standard recently introduced rules for the encoding, transmission and storage of the structured diagnostic report. This medical document can be stored and communicated with the images. It has a structure and may contain text, with links to other data such as images, waveforms and spatial or temporal coordinates. The prompt availability of the radiology report is crucial for implementing a Patient Electronic Record. Using the extensible markup language (XML) to encode the radiology report broadens its accessibly. This paper presents a document type definition (DTD) that accurately models the DICOM structured report content, structure, and constraints.

Abstracting and Indexing↗

PubMed2005

Traumatic impact predicts long-term memory for documented child sexual abuse.

Prospective studies of adults' memories of documented child sexual abuse (CSA) reveal that the majority of individuals remember their victimization. However, the accuracy of these memories has rarely been investigated scientifically. The present study examined predictors of memory accuracy and errors 12 to 21 years after abuse ended for individuals with legal experiences resulting from documented CSA. Severity of posttraumatic stress disorder (PTSD) symptomatology was positively associated with memory accuracy. However, individuals nominating CSA as their most traumatic life event exhibited relatively accurate memory regardless of indicators of PTSD. Predictors of memory errors were also identified (e.g., less maternal support). These results indicate that, in addition to understanding the role of traditional cognitive factors, understanding an event's traumatic impact is important for predicting the accuracy of long-term memory for reported CSA.

Adolescent↗

PubMedDate not supplied

A critical discourse analysis of provision of end-of-life care in key UK critical care documents.

UNLABELLED: This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services. BACKGROUND: A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided. METHODS: A critical discourse analysis (CDA) of four key UK critical care documents published since 1996. FINDINGS AND RECOMMENDATIONS: The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.

Attitude of Health Personnel↗

PubMed2005

Insights into creation and use of prescribing documentation in the hospital medical record.

RATIONALE, AIMS AND OBJECTIVES: Extraction of prescribing data from medical records is a common, albeit flawed, research method. Yet little is known about the processes that result in those data. This study explores the creation and use of prescribing documentation in the medical record, from the perspective of the hospital doctors who both create and use it. METHODS: Thirty-six hospital doctors were purposely selected for qualitative interviews, giving a maximum variability sample of grades of doctors across the range of major medical specialty areas and medical teams at a large teaching hospital in England. RESULTS: The findings suggest a number of reasons why hospital doctors fail to record prescribing decisions in the medical record. There was no set standard, record keeping was not formally taught and the hurried environment of the ward gave little time for documentation. The doctors also acknowledged that there was no need for completeness, as colleagues would be able to 'fill in the gaps' via an inferential process. Assumptions were made and although this was not seen as ideal, it was recognized as necessary if work was to be done efficiently. CONCLUSION: These results reinforce the suggestion that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge. This has profound implications for those without that insider knowledge who are using medical records for research purposes. FUNDING: This work was funded by a North West Regional National Health Service Postdoctoral Fellowship.

Attitude of Health Personnel↗

PubMed2004

Structuring the documentation of nursing care on the basis of a theoretical process model.

The aim of this study was to develop the documentation of the substance of nursing care on the basis of a theoretical caring process model. The theory is Eriksson's caring process model and her theory of health, suffering and caring. The approach of the research task was dialogue. As a research method Koski's adaptation of Gadamer's theory of hermeneutic experience was used, in which Gadamer's hermeneutic text interpretation is divided into four phases. The phases are the explicit analysis of preunderstanding, hermeneutic dialogue, the merging of horizons and active application. The dialogue is carried on between Eriksson's theory of health, suffering and caring and clinical nursing practice and between the caring process model and nursing practice. The goal is to achieve a new scientific view on which to base the documentation of nursing care. As a result of the dialogue a classification in accordance with Eriksson's caring-process model is presented. In the next phase of the study the classification is piloted in a clinical context. The purpose is to obtain knowledge of whether the suggested classification describes what, according to the theory, it should describe.

Data Collection↗

PubMed2006

Three-dimensional documentation of wound healing: first results of a new objective method for measurement.

BACKGROUND: The objective assessment of wound healing is one essential parameter of quality assurance in a modern chronic wound management program. In the past assessment has been based exclusively on a two-dimensional measurement of the wound surface with planimetry or digital photo documentation in combination with such measurements. An objective method for measuring the volume of chronic wounds has not yet been available. PATIENTS AND METHODS: In cooperation with the company RSI, we linked digital photography, optical raster by means of digital scanner, and picture processing software (DigiSkin) for an exact three-dimensional image of chronic wounds. The generated point clouds allow the visual, computer-assisted three-dimensional quantification and can document the course of healing of chronic wounds. RESULTS: In comparison to currently available systems, our new method makes possible the objective measurement of volume changes and wound healing course in chronic wounds.We demonstrate the utility of the system in reference to three patients with chronic venous leg ulcers. CONCLUSIONS: Using this new, objective three-dimensional wound measurement system,it is possible to reliably quantify changes in wound healing for the first time. Future clinical studies have a new option for the gathering of data which will facilitate evidenced-based conclusions.

Aged↗

PubMed1990

Immunisation state and its documentation in hospital patients.

Two prospective surveys of the immunisation state and its documentation were conducted among children under 2 years old attending a children's hospital. A survey of 111 children attending the casualty or outpatient departments showed that, according to reliable records, 106 (95%) were fully immunised for age with oral polio vaccine, 93 (84%) with triple antigen, and 26 of 33 children greater than or equal to 16 months of age (79%) with measles-mumps vaccine. A survey of 204 inpatients showed that, according to verified records, significantly fewer inpatients than outpatients were fully immunised for age with oral polio vaccine (176, 86%) and with triple antigen (144, 71%). The proportion of inpatients vaccinated with measles-mumps vaccine was 81% (48 of 59). The inpatient figures are all lower than the 95% goal of current child immunisation programmes. Although parents of 98% of inpatients had a personal health record for the child, it was available at the time of admission for less than half the children. Lack of use of the personal health record by admitting medical staff was reflected in incorrect or absent documentation of the immunisation state in 17 of 49 (35%) of the records of children verified to have inadequate immunisations. Parents and health care staff need to be educated in the optimal use of the personal health record. Hospital paediatric staff need to be encouraged to verify the immunisation state of all young children, on admission, and arrange to rectify any deficiency found.

Child↗

PubMed1989

Automatic electronystagmus analysis and documentation: recent advances in the study of vestibular, optokinetic and pursuit tracking function.

A normal or pathologically altered peripheral vestibular system and associated brainstem structures can be diagnosed from the pattern of eye movement responses elicited by appropriate stimuli. Recent advances in two stages crucial to an accurate assessment of pathological or normal responses are described in this article. The first stage involves the automatic analysis of electronystagmus signals to yield the main parameters of clinical and scientific interest, slow phase eye velocity and fast phase frequency. Since four algorithms based on the first derivative of eye position perform this task remarkably well on-line, it is not necessary to employ features of the stimulus to separate the slow and fast phases of nystagmus. Examples are used liberally to illustrate the accuracy, advantages and limitations of the algorithms. The second stage involves a numerical and graphical comparison of measurements from a patient's analyzed responses with normal responses. This documentation phase permits immediate recognition of normal, borderline, or pathological optokinetic, eye tracking, caloric and rotating chair test results. Selected examples of pathological responses illustrate the documentation technique.

Algorithms↗

PubMedDate not supplied

Documentation in pediatric laryngology.

Endoscopy in pediatric laryngology continues to develop and broaden its horizons. The need for documentation of the various pathological conditions has become more apparent. The upper lateral airways radiological study together with endoscopic photography allows permanent objective documentation of the changes occurring in any part of the upper respiratory tract from the nose and nasopharynx to the bronchi and segmental openings. This combination of radiological study and single frame color photography is the most convenient means of studying the pathology, natural history, and results of treatment as well as for clinical research and teaching in training programs.

Child↗

PubMed1992

Documentation of paediatric assessments using the occupational therapy guidelines for client-centred practice.

Although documentation is required in occupational therapy, there is little uniformity in content or format between therapists or facilities. The purpose of this article is to present a format that reflects the Canadian Guidelines for the Client-Centred approach to assessment and to share the experience of implementing this format at the Arbutus Society for Children in Victoria, British Columbia. It is hoped that client-centred documentation will facilitate role clarification, service promotion, and quality assurance. As the format reflects the conceptual framework described in the Occupational Therapy Guidelines for Client-Centred Practice (Canadian Association of Occupational Therapists, 1991b), it should be appropriate for use in other areas of practice.

British Columbia↗

PubMed1991

Failure to document.

The failure to adequately document events in the written clinical record is the major reason for letters of inquiry from Peer Review Organizations (PROs). The major causes of inadequate documentation are time pressures, the mind set of physicians, increasing subspecialization with the fragmentation of patient care, and a distrust of review activities in general. However, the accurate recording of medical events that ensue during the course of caring for patients is an integral aspect of the profession of medicine.

Documentation↗

PubMed2005

Procedure documentation in emergency medicine residencies: a time of change.

OBJECTIVES: The purpose of this study was to identify the methods of procedure documentation (PD) used by emergency medicine residency programs and to ascertain the number of programs that are transitioning to a more advanced system. METHODS: All 122 ACGME-approved allopathic emergency medicine programs were contacted by telephone in December 2001. Survey information was obtained from the program director, an attending physician, a resident, or the residency coordinator. RESULTS: The response rate was 92.6%. Seventeen programs (15%) reported using multiple methods of PD, with only 8% utilizing a formal database. Fifty-five percent reported that PD was manual. One third of all programs utilized a Web-based system for PD, while 13% required the use of personal digital assistants (PDAs). Nearly one fifth of programs stated they were changing to another form of PD, with the majority of those changing to a PDA format. Fifteen percent of programs purchased PDAs for their residents, and a similar proportion reported that the PDA was used by "most or all" of their residents to document procedures. Nearly four times as many programs (64%) reported that "most or all" of their residents utilized PDAs for clinical purposes. CONCLUSIONS: PDAs are used by a majority of residents for clinical purposes, although fewer utilize this resource for PD. Although most emergency medicine residency programs still utilize a manual system for PD, many programs are in transition to a more technologically advanced method.

Computers, Handheld↗

PubMed1984

Documentation: key to survival in child life services.

With the increased demands placed on hospital resources, the need for a comprehensive documentation and program accountability system becomes paramount. In addition to the provision of services, the child life specialist must generate written program description and policy and procedure manuals, participate actively in patient charting, maintain quantitative records of clientele served, and perform program evaluation. It is only through such comprehensive documentation efforts that child life and activity therapy programs can demonstrate to administrative personnel: (a) program philosophy and direction, (b) quality, cost-effective patient care, and (c) program effectiveness. The neglect of these important managerial practices could prove detrimental to the continued survival of child life programs.

Child↗

PubMed2005

[Guideline on radiation protection in medicine requires documentation of radioiodine therapy and follow-up: What are the benefits of an electronic database?].

AIM: The lately updated German guideline on radiation protection in medicine (Richtlinie Strahlenschutz in der Medizin) requires the physician who administers radioactive substances for therapy, to perform and document follow-ups. In order to decrease the administrative burden, an electronic database was developed that interfaces with a word processing software to generate written reports and statistic analysis. METHODS: Based on Microsoft Access and Microsoft Visual Basic a database was created to monitor patients with benign and malignant thyroid disorders after radioiodine therapy. It permits automatic creation of therapy documents and necessary patient reports in Microsoft Word. Intuitive handling, third level of normalization in database architecture and automatic plausibility checks guarantee integrity of the data and the efficacy of the database. RESULTS, CONCLUSION: The new software has been a success in over 1500 patients and over 3800 in- and outpatient therapies and visits. The effort of data entry is easily offset by the automatic generation of the necessary patient reports. The required supervision of the follow-up appointments is now also user-friendly and efficient.

Databases, Factual↗

PubMed2004

Use of incident reports by physicians and nurses to document medical errors in pediatric patients.

OBJECTIVES: To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports. METHODS: A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large children's hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with chi(2) tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors. RESULTS: A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported <20% of their perceived medical errors in the previous 12 months, and 32.6% had reported <40% of perceived errors committed by colleagues. After controlling for potentially confounding variables, nurses were significantly more likely to report >or=80% of their own medical errors than physicians (odds ratio: 2.8; 95% confidence interval: 1.3-6.0). Commonly listed reasons for underreporting included lack of certainty about what is considered an error (indicated by 40.7% of respondents) and concerns about implicating others (37%). Potential interventions that would lead to increased reporting included education about which errors should be reported (listed by 65.4% of respondents), feedback on a regular basis about the errors reported (63.8%) and about individual events (51.2%), evidence of system changes because of reports of errors (55.4%), and an electronic format for reports (44.9%). Although virtually all respondents would likely report a 10-fold overdose of morphine leading to respiratory depression in a child, only 31.7% would report an event in which a supply of breast milk is inadvertently connected to a venous catheter but is discovered before any breast milk goes into the catheter. CONCLUSIONS: Medical errors in pediatric patients are significantly underreported in incident report systems, particularly by physicians. Some types of errors are less likely to be reported than others. Information in incident reports is not a representative sample of errors committed in a children's hospital. Specific changes in the incident report system could lead to more reporting by physicians and nurses who care for pediatric patients.

Attitude of Health Personnel↗

PubMed2003

The dermatologist's academic portfolio: a template for documenting scholarship and service.

The clinician-teacher of dermatology often seeks recognition for academic efforts, the most visible of which is a university appointment with the potential for promotion. Success in achieving this goal requires careful planning to ensure effective involvement in academic pursuits that serve the mission of the university, and there must be concomitant documentation of this involvement. The template in this article provides one format for organizing an academic portfolio that stimulates prospective documentation and enhances the possibility of academic advancement.

Career Mobility↗

PubMedDate not supplied

Video-based documentation and rating system of the motor behaviour of handicapped children treated with physiotherapy--a new outcome measure.

PURPOSE: Development of an instrument to measure modifications of motor quality in handicapped children receiving physiotherapy. METHODS: A video-based documentation method of motor behaviour in children from 0 to 3 years receiving physiotherapy was elaborated, consisting of a standardized set of scenes (script) and a rating procedure concerning different categories of motor behaviour such as coordination, stability and effort. RESULTS: The construction of the script and the rating system proved to be sensitive in documenting and evaluating the motor behaviour of handicapped children receiving physiotherapy. A good inter-rater reliability of 0.85 was obtained. The chosen rating categories represent two independent factors: One relating more to the motor functions (motor component) and the other relating to the psycho-social aspects of movement (interactive component). CONCLUSION: The instrument allows to evaluate the quality aspects of movement. They can be observed in motor behaviour regardless of which function is being executed and may develop in a different pace and at different stages of therapy than specific motor functions such as turning, sitting or walking. The instrument is intended to complement a standard neurological examination and the application of motor function tests, especially, to evaluate therapeutic outcomes.

Child, Preschool↗

PubMed2004

Malignant progression in meningioma: documentation of a series and analysis of cytogenetic findings.

OBJECT: The malignant progression of benign tumors is well documented in gliomas and other systemic lesions. It is also well known that some meningiomas become progressively aggressive despite their original benign status. The theory of clonal evolution is widely believed to explain malignant progression in meningioma; however, the data used to explain stepwise progression have typically been derived from the cytogenetic analysis of different types of tumors of different grades and in different patients. In this study, the authors examined the data obtained in a group of patients with meningiomas that showed clear histopathological progression toward a higher grade of malignancy and then analyzed the underlying cytogenetic findings. METHODS: Among 175 patients with recurrent meningiomas, 11 tumors showed a histopathological progression toward a higher grade that was associated with an aggressive clinical course. Six tumors progressed to malignancy and five to the atypical category over a period averaging 112 months. Tests for MIB-1 and p53 and cytogenetic studies with the fluorescence in situ hybridization (FISH) method were performed in successive specimens obtained in four patients. The MIB-1 value increased in subsequent samples of tumors. Cytogenetic analysis with FISH showed deletions of 22, 1p, and 14q. In all but one case, these aberrations were also present in the previous specimen despite its lower hispathological grade. CONCLUSIONS: The authors documented the progression of meningiomas from benign to a higher histological grade. These tumors were associated with a complex karyotype that was present ab initio in a histologically lower-grade tumor, contradicting the stepwise clonal evolution model. Although it was limited to the tested probes, the FISH method appears to be more accurate than the standard cytogenetic one in detecting these alterations. Tumors that present with complex genetic alterations, even those with a benign histological grade, are potentially aggressive and require closer follow up.

Adult↗