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At least 1,117 records · Page 62Linked to original sources
PubMed1993

Patterns of infant mortality from Armenian parish records: a study from 10 countries of the diaspora, 1737-1982.

Using parish records from 10 different countries with small Armenian communities, this study compared patterns of infant mortality in these countries over a period of 245 years. Deaths registered as aged < or = 1 year were used to estimate the numerator for the infant mortality rates (IMR) while the denominator was estimated from births in the same year based on baptisms in the appropriate registers. To check on the validity of using the baptisms as the denominator for the IMR, records of infant deaths were linked with the baptismal records. Thus, from a sample of 273 infant deaths 78.4% had a baptismal record in the registers of the same church in which the death was recorded. Of the deaths 60% had a recorded cause of death. Over the past 245 years, IMR have fallen substantially in all parishes. However, there were notable exceptions to this general pattern of declining IMR over time. For example, the IMR was tripled in Palestine during the decade of the First World War, possibly as a result of the influx of refugees deported from Turkey. A study of the seasonal occurrence of the deaths revealed peaking of deaths between May and August, a pattern influenced by the relative importance of gastroenteritis as a cause of death during the summer months in Egypt where the majority of these infant deaths were recorded. A review of the most important causes of death helped identify an outbreak of undetermined cause in Belgrade in 1737 and an outbreak of dysentery deaths in Alexandria, Egypt, in 1909.(ABSTRACT TRUNCATED AT 250 WORDS)

Armenia↗
PubMed1994

An audit of occupational medicine consultation records.

There is a need to develop and test methods of audit of the consultation process in occupational medicine and to draw conclusions from the findings. An external audit was carried out on 313 randomly selected consultation records from the occupational health services of three health boards over a 26-month period. Additionally, nine months after the date of the first externally audited sample, a prospective internal audit was commenced within one board. In 58 of the consultations selected (19 per cent), audit was not possible mainly because records could not be found. In an appreciable proportion of the rest, there were shortcomings in the referral record or in the consultation record. The consultation records of 'career' occupational physicians were better than those of 'non-career' physicians, especially in recording specific diagnoses (91 per cent vs. 67 per cent; P < 0.0001) and in conclusions regarding occupational implications (86 per cent vs. 74 per cent; P < 0.0001). Multivariate regressions showed a highly significant improvement associated with prospective internal audit in one item, namely the record of occupational implications. However, the magnitude of this difference before and after audit was smaller than the independent difference arising from the career status of the physicians. The value of medical audit in improving quality of care and education in occupational medicine is discussed.

Adult↗
PubMed1996

Dietary assessment in epidemiology: comparison on food frequency and a diet history questionnaire with a 7-day food record.

The validity of two types of diet assessment methods, a self-administered food frequency questionnaire and and interviewer-administered detailed diet history, was assessed relative to a 7-day food record on a population- based sample of 95 men and 108 women in Toronto, Canada, between May 1989 and July 1990. Each study subject completed both questionnaire methods, a food frequency questionnaire and an interviewer-administered diet history, as well as a 7-day food record in a crossover design. Data were analyzed for both unadjusted and energy-adjusted nutrients to estimate Pearson's and intraclass correlations and agreement within the categories. Mean values for the intake of most nutrients assessed by the two questionnaire methods were similar. Average, energy-adjusted Pearson's correlation coefficients for men between a food frequency questionnaire and a 7-day food record were 0.55 for macronutrients and 0.48 for micronutrients compared with 0.47 for macro- and 0.48 for micronutrients between an interviewer-administered diet history and a 7-day food record. For women, they were 0.48 for macro- and 0.54 for micronutrients between a food frequency questionnaire and a 7-day food record and 0.46 and 0.49, respectively, between an interviewer-administered diet history and a 7-day food record. The energy-adjusted Pearson correlations were generally higher than were the energy-unadjusted Pearson correlations and the intraclass correlations. The present study suggests that a food frequency questionnaire is comparable with an interviewer-administered diet history as a predictor of nutrients as estimated form a 7-day food record.

Adult↗
PubMed1981

Requesting previous psychiatric records. Do they come and are they worth obtaining?

This study examines the response rate to requests for previous records on adult psychiatric outpatients and the usefulness of the records received. Usable records were received in response to only 64.6 per cent of requests. In 40.9 per cent of the records examined, previous records revealed important information which had not been gathered at the time of outpatient evaluation. Possible reasons for the rate of response are discussed. The authors conclude that important information can be missed during the process of evaluation and that previous records may significantly add to the available data base on which to make diagnostic and treatment decisions. However, not infrequently requests for previous records are not answered.

Adult↗
PubMed1981

The validity of the medical record.

The medical record is the source of information for many purposes, including evaluation of the quality of care provided. Despite this reliance on the record, there have been few attempts to validate the recorded content against the verbal content of the interaction between patient and physician. In this study, we compared the record with verbatim transcripts of outpatient visits. Overall, 59 per cent of units of information present in either source were found in the record. Recording was more complete for the chief complaint (92 per cent) and information related to the patient's present illness (71 per cent) than for other medical history (29 per cent). Incomplete recording of elicited information may partially explain the often low levels of performance of recommended care items found in quality-of-care studies. We suggest that more attention be paid to improving communication about tests and therapies to patients.

Adolescent↗
PubMed1987

Pneumonia--the quality of medical records data.

The quality of medical records data for patients who were hospitalized with community-acquired pneumonia was assessed by comparing medical records data with data obtained in a prospective study of pneumonia for the period April 1, 1984, to December 31, 1984. One hundred five patients fulfilled the case definition of pneumonia for entry into the prospective study. One hundred twenty-seven patients were identified by medical records data. Seventy-three of the patients appeared in both studies. The positive predictive accuracy of the medical records data was 57%. When the etiologic diagnoses for the 73 patients identified by both studies were compared, there was agreement only 52.6% of the time. Streptococcus pneumoniae was overdiagnosed, and Mycoplasma, specific viral causes, and Haemophilus influenzae were not recorded by the medical records data. The quality of medical records data regarding pneumonia can be improved by changing the current ICD-9-CM coding system for pneumonia and by providing instruction and an algorithm for abstractors to follow in assigning a diagnosis of pneumonia.

Humans↗
PubMed1996

Optometric record keeping in a comprehensive health care environment.

Optometric records which have evolved in private practice must be reconsidered when included in a comprehensive care environment. These hospital, health maintenance organization (HMO), preferred provider organization, and similarly linked systems require a higher degree of communication among specialties than do self-standing practices. Furthermore, the administrative requirements of such a system require more standardization, cost sensitivity, medicolegal compliance, and other elements pecular to a comprehensive facility. The expended scope of care provided by optometrists within a hospital requires familiarity with a new range of procedures, languages, and reports. Information from laboratories, radiology, and other areas must be incorporated into the optometric record. Continuity of care is more complex. Opportunities for strong interprofessional synergies within the organization arise directly from proactivity in optometric record keeping. New legal hot spots arise from questions of records ownership, access, and privacy. Billing procedures are becoming extremely important, with significant effects on quality assurance audits, coding, doctor "profiling" against fraud, and abuse; these priorities can interfere with clinical priorities. Driven primarily by the concerns and resources of large third-party payers, technology is making rapid changes in the form of optometric record keeping in comprehensive systems. Electronic data management will change the face of medical records, although administrative data will be digitized much more quickly than clinical notes. Comprehensive care environments will be the "test beds" for these technologies. Optometry is in a good position to show its contribution to the health care team through leadership in the implementation of new record keeping models.

Comprehensive Health Care↗
PubMed2004

Clinical holistic medicine: the "new medicine", the multiparadigmatic physician, and the medical record.

The modern physician is often multiparadigmatic as he serves many different types of people in many different existential circumstances. The physician basically often has three, very different sets of technologies or "toolboxes" at his disposal, derived from three different medical paradigms: classical, manual medicine; biomedicine; and holistic or consciousness-oriented medicine. For lack of a better term, we have called the extended medical science--integrating these three different paradigms and their three strands of tools and methods--the "new medicine". The excellent physician, mastering the "new medicine", uses the most efficient way to help every patient, giving him or her exactly what is needed under the circumstances. The excellent physician will choose the right paradigm(s) for the person, the illness, or the situation, and will use the case record to keep track of all the subjective and objective factors and events involved in the process of healing through time. The case or medical record has the following purposes: A. REFLECTION: To keep track of facts, to provide an overview, to encourage causal analysis, to support research and learning, and to reveal mistakes easily. B. COMMUNICATION: To communicate with the patient with a printout of the case record to create trust and help the patient to remember all assignments and exercises. C. EVIDENCE AND SAFETY: To provide evidence and safety for the patient or to be used in case of legal questions. D. SELF-DISCIPLINE: To encourage discipline, as a good case record is basically honest, sober, brief, and sticks to the point. It forces the physician to make an effort to be more diligent and careful than a busy day usually allows. The intention of the case or medical record is ethical: to be sure that you, as a physician, give the best possible treatment to your patient. It helps you to reflect deeply, communicate efficiently, provide evidence and safety, and back your self-discipline, never to be carried away by the high speed of modern-day clinical work to give less than the optimal treatment. The patient"s life, now and in the future, is in the palm of your hand, and to assume this huge responsibility, the physician must be anxious and careful about the quality of the medical record. Much too often, the essence of the session is nowhere to be found in the case record, so most of the generated value is lost between consultations.

Holistic Health↗
PubMed2004

Independent component analysis removing artifacts in ictal recordings.

PURPOSE: Independent component analysis (ICA) is a novel algorithm able to separate independent components from complex signals. Studies in interictal EEG demonstrate its usefulness to eliminate eye, muscle, 50-Hz, electrocardiogram (ECG), and electrode artifacts. The goal of this study was to evaluate the usefulness of ICA in removing artifacts in ictal recordings with a known EEG onset. METHODS: We studied 20 seizures of nine patients with focal epilepsy monitored in our video-EEG monitoring unit. ICA was applied to remove obvious artifacts in segments at the beginning of the seizure. The final EEGs were exported to the original format and were compared with the original EEG by two blinded examiners. We compared original recordings and the samples cleaned by digital filters (DFs), ICA and ICA plus digital filters (ICA + DFs), evaluating the possibility of finding an ictal pattern, the localization of the onset in area and time, and the global quality of the sample. RESULTS: All the recordings except one (95%) improved after the use of ICA for the elimination of blinking and other artifacts. Three seizures were found in which in the original recordings did not permit us to detect an ictal pattern, and after ICA + DFs, an ictal onset was evident; in two of them, ICA alone was able to show this pattern. The best results in all the scores were obtained with ICA + DF. ICA was better than DFs. The agreement between the two reviewers was highly significant. CONCLUSIONS: ICA is useful to remove artifacts from ictal recordings. When applied to ictal recordings, it increases the quality of the recording. In some cases, ICA may be useful to show ictal onsets obscured by artifacts. ICA + DFs obtained the best results regarding removal of the artifacts.

Adult↗
PubMed2005

Health professionals rarely record history of complementary and alternative medicines.

AIMS: To identify the completeness of documentation of Complementary And Alternative Medicine (CAM) use in hospital medical records of patients before and after an education programme. METHODS: Documentation of CAM in all parts of the medical records was compared to patients' self-reported use. Data were collected for one month before and one month after an education programme for hospital staff. RESULTS: At baseline: 59 (58%) of 101 patients used 129 CAM in the month prior to admission; only 36 (28%) of the CAM were documented in the medical record. After education: 51 (54%) of 94 patients used 91 CAM in the month prior to admission; 40 (44%) of the CAM were documented in the medical record. After education, recording rates increased by 16% (95% CI: 3% to 29%) due to improvements by pharmacists (18%, 95% CI: 5% to 31%). 32 (54%) of CAM users at baseline and 29 (57%) of CAM users after education informed a health professional. The recording rates were only 23 (39%) and 28 (55%) respectively for patients in these two sub-groups, being an improvement of 16% (95% CI: -2% to 34%). CONCLUSIONS: Prevalence of CAM use among patients admitted to hospital is high, but documentation of usage is low. Strategies need to be designed to improve health professionals' knowledge about the need to record history of CAM use.

Adult↗
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↗
PubMed2005

Long-term utility of measuring adherence by self-report compared with pharmacy record in a routine clinic setting.

OBJECTIVES: To compare long-term adherence to antiretroviral therapy in an HIV service, as measured by self-report and by pharmacy records. To determine the level of adherence by each measure required to suppress viral load in a majority of patients. METHODS: The percentage of prescribed doses taken was calculated from (a) the number of missed doses in the previous 28 days reported by patients in a questionnaire at each clinic visit, and (b) pharmacy dispensing records. These were compared with each other and with HIV viral load data. RESULTS: Mean adherence was 96.2% by pharmacy record over 44 months and 98.6% by self-report over 25 months. The two methods correlated with each other (P<0.001) and the proportion of patients with viral load <400 HIV-1 RNA copies/mL increased with adherence as measured by self-report (P=0.001) and pharmacy record (P=0.004). Fewer than 60% of patients always had viral loads <400 copies/mL if adherence fell below 95% (pharmacy record) or 97% (self-report). Adherence was higher for once-daily than for twice-daily therapy (by pharmacy record: 97.2% vs. 96.0%; P<0.001). Adherence by both measures increased over time. CONCLUSIONS: Self-reported antiretroviral adherence correlates with pharmacy dispensing records and predicts suppression of viral load at levels >or=97%. It is practical to adopt this into routine HIV clinical care.

Ambulatory Care Facilities↗
PubMed2006

Agreement between hospital records and maternal recall of mode of delivery: evidence from 12 391 deliveries in the UK Millennium Cohort Study.

OBJECTIVE: The objective of this study was to measure the agreement between hospital records and maternal reporting of mode of delivery in a representative UK sample. DESIGN: Population-based survey (Millennium Cohort Study). SETTING: UK. POPULATION: A total of 12,391 singleton infants born in 2000-2002. METHODS: Mothers were interviewed when infants were approximately 9 months old. Information was collected by interview on many obstetric and perinatal factors including mode of delivery. Record linkage to the mother's delivery hospital records was undertaken in those who gave consent (90%). A matching record was found for 83%. Maternal report and hospital records were compared using mode of delivery classified into three (normal, assisted and caesarean) and six groups. Factors associated with disagreement between the two data sources were identified. MAIN OUTCOME MEASURE: Proportion of records in which there was agreement between the two data sources. RESULTS: Agreement between maternal report and hospital records was at least 94% using six mode of delivery groups and 98% using three groups. Much of the disagreement (57-63%, depending on country) was between forceps and ventouse, and between planned and emergency caesarean. Disagreement was more common in women whose babies were first born and in women not born in the UK. CONCLUSION: Our study confirms that maternal reporting of mode of delivery is highly reliable. This is important for clinical staff caring for women and those conducting epidemiological studies. Additional data sources may be necessary to gather reliable data from ethnic minority women, particularly those born outside the UK, or to distinguish forceps from ventouse, or planned from emergency caesarean section.

Cohort Studies↗
PubMed2005

Adding video recording increases the diagnostic yield of routine electroencephalograms in children with frequent paroxysmal events.

PURPOSE: To report on the usefulness of adding video recording to routine EEG studies of infants and children with frequent paroxysmal events. METHODS: We analyzed the efficacy of this diagnostic means during a 4-year period. The decision whether to add video recording was made by the pediatric EEG interpreter at the time of the study. Studies were planned to last between 20 and 30 min, and, if needed, were extended by the EEG interpreter. For most studies, video recording was added from the beginning of EEG recording. In a minority of cases, the addition of video was implemented during the first part of the EEG test, as clinical events became obvious. In these cases, a new study (file) was begun. The success rate was analyzed according to the indications for the EEG study: paroxysmal eye movements, tremor, suspected seizures, myoclonus, staring episodes, suspected stereotypias and tics, absence epilepsy follow-up, cyanotic episodes, and suspected psychogenic nonepileptic events. RESULTS: Video recording was added to 137 of 666 routine studies. Mean patient age was 4.8 years. The nature of the event was determined in 61 (45%) of the EEG studies. Twenty-eight percent were hospitalized patients. The average study duration was 26 min. This diagnostic means was particularly useful for paroxysmal eye movements, staring spells, myoclonic jerks, stereotypias, and psychogenic nonepileptic events. About 46% of 116 patients for whom cognitive data were available were mentally retarded. EEG with added video recording was successfully performed in all 116 cases and provided useful information in 29 (55%) of these 53 patients. CONCLUSIONS: Adding video recording to routine EEG was helpful in 45% of cases referred for frequent paroxysmal events. This technique proved useful for hospitalized children as well as for outpatients. Moreover, it was successfully applied in cognitively impaired patients. Infants and children with paroxysmal eye movements, staring spells, myoclonic jerks, stereotypias, and pseudoseizures especially benefited from this diagnostic means. Because of its low cost and the little discomfort imposed on the patient and his or her family, this technique should be considered as a first diagnostic step in children with frequent paroxysmal events.

Age Factors↗
PubMed1994

Hygienist employment and the presence of periodontal notations in general dental practice patient records.

Available data suggest that the provision of periodontally related services in general dental practices is low. However, studies indicate that the employment of dental hygienists is associated with increased provision. One method of measuring is by examination of notations in patient treatment records. As part of a project assessing the effectiveness of professional education in changing the provision of periodontal services, 2280 records, comprising 60 randomly selected records of dentate adult patients who had received a dental examination in the previous 6 months were audited in each of 38 practices, 13 of which employed hygienists. Entries of a periodontal nature were classified under 3 categories: diagnostic, preventive and treatment. The presence or absence of each item on each record was recorded. Diagnostic services were notated infrequently overall, but practices employing hygienists had a significantly lower number of records with no diagnostic notations. Preventive items were more frequently notated in practices employing hygienists. Treatment items were most frequently notated in both types of practices. Overall, 13 of the 23 items were recorded significantly more frequently in practices employing hygienists.

Adult↗
PubMed1984

Evaluation of a home based health record booklet.

Despite the widespread use of home based child health records of varying complexity in England, there is a notable absence of their evaluation. Such a record booklet developed in the West Lambeth Health Authority has been used by parents, doctors, and community nurses to build up an independent chronological record of a child's birth statistics, health, growth, immunisation, development checks, and contacts with health services. A randomised controlled evaluation of the record, analyses of entries in it, and a survey of the views of mothers and health professionals using the record have been carried out. The need for such a record was confirmed by those questioned and analyses of entries in the booklet helped to modify and improve it. The evaluation was unable to show, however, any effect of the record on immunisation and developmental assessment service uptake. Its value in improving communication between the numerous health and other care agencies was dependent on its proper use.

Body Weight↗
PubMed1987

Personal health records: an evaluation.

A cohort of mothers whose babies were born over one calendar month were followed up eight to 11 months after being given a personal health record for their newborn babies. Eight per cent of mothers lost the records and three more said they had not been given a record while in hospital; a total of 10% of mothers had either lost or misplaced the record. There were no particular demographic characteristics which identified the mothers who were more likely to lose the record. Most parents liked personal health records and used them frequently, as did the community health staff. Most private doctors, however, did not find them useful. Before wider distribution of such records is contemplated health workers should be adequately prepared, especially doctors in the private sector.

Attitude of Health Personnel↗
PubMed1996

Practicality of recording patient ethnicity in general practice: descriptive intervention study and attitude survey.

OBJECTIVE: To assess the feasibility of recording patient ethnicity in primary care using the Office of Population Censuses and Surveys classification. DESIGN: A descriptive intervention study and attitude survey in random samples of adults and primary care staff in randomly selected practices. SETTING: Eight practices in Lincolnshire and seven in Leicester. SUBJECTS AND METHODS: When patients were asked their ethnicity by general practitioners, nurses, or receptionists data were collected for 863 of a possible 880 patients. Of 750 patients sent a questionnaire about their attitudes towards the collection of such data 489 responded. Ninety five primary care staff completed a similar questionnaire. MAIN OUTCOME MEASURES: Time taken to record a patient's ethnicity; attitudes of patients and staff towards such recording, including who should ask, who can respond for others, and whether data can be shared with secondary care. RESULTS: Recording the data took less than a minute for three quarters of patients, but even this would need an average of a week of receptionist time per general practitioner. 72% of patients and 57% of staff agreed that ethnic data could be shared with secondary care, and 73% of patients and 60% of staff felt that the data should probably be collected in general practice. CONCLUSIONS: Ethnicity recording in general practice is feasible and acceptable. Nevertheless, the role of ethnic data in assessing health need in primary care, an adequate recording system, and evidence that recording offers benefits greater than the costs need to be established.

Attitude↗