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At least 1,135 records · Page 63Linked to original sources
PubMed2006

Use of personal child health records in the UK: findings from the millennium cohort study.

OBJECTIVES: The personal child health record (PCHR) is a record of a child's growth, development, and uptake of preventive health services, designed to enhance communication between parents and health professionals. We examined its use throughout the United Kingdom with respect to recording children's weight and measures of social disadvantage and infant health. DESIGN: Cross sectional survey within a cohort study. SETTING: UK. PARTICIPANTS: Mothers of 18,503 children born between 2000 and 2002, living in the UK at 9 months of age. MAIN OUTCOME MEASURES: Proportion of mothers able to produce their child's PCHR; proportion of PCHRs consulted containing record of child's last weight; effective use of the PCHR (defined as production, consultation, and child's last weight recorded). RESULTS: In all, 16,917 (93%) mothers produced their child's PCHR and 15,138 (85%) mothers showed effective use of their child's PCHR. Last weight was recorded in 97% of PCHRs consulted. Effective use was less in children previously admitted to hospital, and, in association with factors reflecting social disadvantage, including residence in disadvantaged communities, young maternal age, large family size (four or more children; incidence rate ratio 0.87; 95% confidence interval 0.83 to 0.91), and lone parent status (0.88; 0.86 to 0.91). CONCLUSIONS: Use of the PCHR is lower by women living in disadvantaged circumstances, but overall the record is retained and used by a high proportion of all mothers throughout the UK in their child's first year of life. PCHR use is endorsed in the National Service Framework for Children and has potential benefits which extend beyond the direct care of individual children.

Body Weight↗
PubMed2000

Quality improvement programme for cardiovascular disease risk factor recording in primary care.

OBJECTIVES: Evaluation of the effect of a quality improvement programme on cardiovascular disease (CVD) risk factor recording and risk factor levels in a controlled study at two primary health care centres serving 26,000 inhabitants in Northern Helsinki. METHODS: From a random sample of patient records from 1995 (n=1,066), 1996 (n=1,042), and 1997 (n=1,040) the frequency of CVD risk factor recording was measured and the changes in mean levels of total cholesterol, blood glucose, blood pressure, and body weight were monitored during the follow up period. The intervention programme (1995-1996) consisted of lectures and meetings of multiprofessional teams, development of local guidelines, and introduction of a structured risk factor recording sheet as part of the patient records. RESULTS: After the quality improvement period all risk factors were better recorded at the intervention station than at the control station (p<0.001). More high risk CVD patients were detected from the general population at the intervention station. The mean values of most measured risk factors changed during the intervention. During the follow up period differences were observed between the two health stations in the time trends for body weight, body mass index (BMI), total cholesterol, and glucose levels. Risk factor levels of high risk patients receiving CVD treatment decreased during the intervention. CONCLUSIONS: A simple quality improvement programme improved the practice of recording risk factors for CVD which resulted in earlier detection of patients with a high risk of developing the disease.

Adolescent↗
PubMed2005

Pursuing integration of performance measures into electronic medical records: beta-adrenergic receptor antagonist medications.

OBJECTIVE: Electronic medical records seldom integrate performance indicators into daily operations. Assessing quality indicators traditionally requires resource intensive chart reviews of small samples. We sought to use an electronic medical record to assess use of beta-adrenergic antagonist medications (beta-blockers) following myocardial infarction, to compare a standardized manual assessment with assessment using electronic medical records, and to discuss potential for future integration of performance indicators into electronic records. DESIGN: Cross-sectional data analysis. SETTING: An urban academic medical center. PARTICIPANTS: US Medicare beneficiaries 65 years of age or older, admitted to hospital with myocardial infarction between 1995 and 1999. MEASUREMENTS AND MAIN RESULTS: Manual chart review was compared with a computer driven assessment of electronic records. Administration of beta-blockers and cases excluded from use of beta-blockers were measured, based on Medicare criteria. Among 4490 older adults, 391 (4%) of 9018 hospital admissions contained codes for myocardial infarction. In 323 (83%) of the 391 hospital admissions, criteria for excluding beta-blockers were met; 235 (60%) were excluded due to heart failure. Of 68 hospital admissions for myocardial infarction that did not meet exclusion criteria, physicians prescribed beta-blockers in 49 (72%) on admission and 42 (62%) at discharge. Compared with manual chart review, electronic review had a sensitivity of 83-100% and led to fewer false negative findings. CONCLUSIONS: An electronic medical records system can be used instead of chart review to measure use of beta-blockers after myocardial infarction. This should lead to integration of real time automated performance measurement into electronic medical records.

Academic Medical Centers↗
PubMed1994

Assessing discomfort after anaesthesia: should you ask the patient or read the record?

OBJECTIVE: To assess the quality of anaesthesia care from the patients' viewpoint compared with the hospital record. DESIGN: Prospective study during 1988-9. SETTING: Four teaching hospitals (A-D) in Canada. PATIENTS: 15,960 inpatients receiving anaesthetic requiring at least an overnight stay, for whom an interview and review of hospital records within 72 hours of surgery were complete. MAIN MEASURES: Rates of postoperative symptoms of discomfort (nausea or vomiting, headache, back pain, sore throat, eye symptoms, and tingling) according to the hospital record versus interview and the relation between symptoms and patients' satisfaction with the anaesthetic experience. RESULTS: The preparation of completed interviews ranged from 31.0% to 72.7%, owing mainly to patients discharge (hospitals A and B) and severity of illness (C and D). Interviewed patients were similar to all inpatients in the hospitals but were younger and healthier and more had had effective operations and were general surgical than cardiovascular or neurosurgical patients. In all, 26% to 46% of patients at the four hospitals reported at least one symptom of discomfort. Agreement between interviews and hospital records was low, symptoms being more commonly reported by interview than in the record (for example, headache was reported for 5.8%-17% of patients compared with 0.3%-3.0% in hospital records). After controlling for case mix patients who reported at least one symptom were 2.91 times (95% confidence interval 1.89 to 4.50) more likely to be dissatisfied with their anaesthetic care than patients who did not. CONCLUSIONS: Anaesthesia services are typically neglected in studies of hospital quality, yet patients express considerable anxiety about anaesthetic care. Monitoring and recording patients' discomfort clearly need to be improved if the quality of anaesthesia is to be properly evaluated.

Adult↗
PubMed1995

Macronutrient, copper, and zinc intakes of young German children as determined by duplicate food samples and diet records.

Daily energy, protein, fat, carbohydrate, zinc, and copper intakes of 47 healthy 5- to 9-year-old children living in Duisburg, an industrial area of North Rhine-Westphalia, and consuming self-selected diets were calculated using a 4-day weighed dietary records and food composition values. In addition, the parents of the subjects also collected a 24-hour food composite on 2 of the recording days for analysis of the nutrients. This allowed us to compare the calculated value of the nutrients on days when only dietary records were made with those on which also duplicate samples were collected. Daily analyzed intakes were also compared with those calculated from the recording days. Zinc and copper were estimated by atomic absorption spectrometry. The results show that there were reductions in the intake of all nutrients on days when duplicate samples were also collected as compared with the days when only dietary records were made. Median daily calculated intakes for all children on the 4 record days were: energy 1,578 kcal, protein 46.5 g, fat 67.3, carbohydrates 174.7 g, zinc 5.3 mg, and copper 1.0 mg. The median analyzed intakes were: energy 1,367.7 kcal, protein 37.1 g, fat 49.1, carbohydrates 178.7 g, zinc 5.3 mg, and copper 0.7 mg. The use of the duplicate diet method has shown that a 4-day recording period gives an overestimation of the nutrient intake. The calculated and the analyzed zinc intakes did not meet the recommended levels of the Deutsche Gesellschaft für Ernährung. The median copper intakes were in the lower range of the levels recommended by the Deutsche Gesellschaft für Ernährung.

Child↗
PubMed2003

Patients' concerns about and perceptions of electronic psychiatric records.

This study assessed concerns about and perceptions of electronic psychiatric records in a university psychiatric adult outpatient clinic. Forty-one patients who refused to have their psychiatric records transferred to the electronic record system were compared with 39 patients who agreed to an electronic record. Regardless of whether or not they refused to have their information transferred to an electronic record, a majority of patients reported numerous concerns about electronic records, such as concerns about unauthorized access to their records by parties within the university health care system. Patients' concerns may affect patient disclosure and other help-seeking behavior and therefore must be addressed by clinicians and health care systems.

Attitude↗
PubMedDate not supplied

Measles immunization coverage determined by serology and immunization record from children in two Chicago communities.

OBJECTIVES: We compared the prevalence of measles immunization determined by serology with the prevalence of measles immunization determined by immunization records, and identified factors predictive of measles immunization among a sample of children from two Chicago communities. METHODS: We collected demographic information and blood specimens from a sample of children aged 12-71 months in two Chicago communities at risk for low measles immunization coverage levels. We collected immunization information from provider records, parent-held records, and the statewide immunization registry. We compared evidence of immunization determined by serology with evidence of immunization from these three sources of immunization records. RESULTS: The sample of children from the two communities had serologic measles immunity levels of 85% and 90%. Significantly fewer children had evidence of immunization by record in both communities (45% and 63%, respectively). CONCLUSIONS: Immunization coverage levels determined using immunization records were significantly lower than immunization coverage determined using serology. A fully populated immunization registry used by all immunization providers could prevent the problems of record loss and scatter.

Chicago↗
PubMed1998

Confidentiality in crisis: Part II--Confidentiality of treatment records.

OBJECTIVE: To discuss the implications of recent legislative changes and court decisions in Canada that have placed the privacy of psychiatric records information at risk. New areas of exposure include client access to clinical information provided by family members, parental access to children's records, and court access to clinical records in civil, criminal, and family law matters. METHOD: A review of recent legislative changes and court decisions pertaining to access to psychiatric records. CONCLUSION: At present, psychiatric records can no longer be regarded as confidential. Recent changes in the concept of privilege of treatment records necessitates several changes in psychiatric practice regarding informed consent to treatment, content of clinical records, and responses to demands for information.

Adult↗
PubMed1998

Food frequency questionnaire versus 7-day weighed dietary record information on dietary fibre and fat intake in middle-aged Swedish men.

To study the magnitude of agreement between a short self-administered food frequency questionnaire and a 7-day weighed dietary record regarding the consumption of fibre and fat, we collected information from 92 randomly selected middle-aged Swedish men. The participants first recorded all foods and drinks consumed over seven consecutive days by means of a digital scale. One month after the 7-day weighed record had been completed, a self-administered food frequency questionnaire on habitual consumption of foods containing fibre or fat during the preceding month was sent to the subjects. The 20 largest contributors of fibre and fat in the diet accounted for 71% and 52% of the total intake, respectively, based on the 7-day weighed record. The estimated mean consumption of fibre was 19.0 grams per day based on the 7-day weighed record and 18.3 grams per day based on the food frequency questionnaire. Corresponding estimated mean consumption of fat was 88.6 grams per day versus 46.9 grams per day. Men with high physical activity and low BMI, respectively, had higher intake of fibre and fat. These differences were seen for both dietary measurement methods but were more marked using the 7-day weighed record. The agreement between methods for each individual was also assessed. Based on five categories of fibre consumption, 61% of the respondents in the highest quintile according to the 7-day weighed record were classified in one of the two highest quintiles according to the food frequency questionnaire. The corresponding figure for fat intake was 56%. We conclude that the short self-administered food frequency questionnaire used in the present study can assess the absolute intake of fibre, but not of fat, with good precision. Also, the ranking of individuals in broad categories of consumption of fibre and fat was not largely misclassified based on this short questionnaire.

Adult↗
PubMed2002

Quality and correlates of medical record documentation in the ambulatory care setting.

BACKGROUND: Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. METHODS: We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care. RESULTS: Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 - 2.83) but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 - 0.75). CONCLUSIONS: Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of characteristics correlated with medical record documentation, but no pattern emerged. Further study could lead to targeted interventions to improve documentation.

Ambulatory Care Information Systems↗
PubMed1988

Presence of periodontal data in patient records of general practitioners.

It has been reported that little diagnostic information concerning periodontal conditions is entered in patient records of general practitioners, but actual rates for such chart entries are unknown. Records of regular patients, seen at least annually, were randomly selected from the offices of 36 general practitioners in two North Carolina counties. In each office 80 records were selected for audit. After adjustment, the final sample consisted of 2488 audited records. Entries noting the presence or absence of 14 diagnostic conditions were identified for the five previous years and for the patient's most recent examination. The presence of a periodontal diagnosis or periodontal treatment plan was noted. The number of radiographic sets exposed in the previous five years and the age of the most recent set were determined for complete series/panoramic films and for bitewings. Across practices, the most frequent notations (20.5% within the past five years) concerned the presence of probing depths and calculus. Gingival bleeding (13%) and plaque (12%) were noted less frequently. A periodontal diagnosis was recorded in only 16.3% of the records. Annualized rates for radiographic sets were 0.09 for complete series/panoramic films and 0.50 for bitewings. These data suggest that, except for radiographs, the majority of patient records do not contain sufficient diagnostic information to describe patients' periodontal health.

Adult↗
PubMedDate not supplied

A Java-based electronic healthcare record software for beta-thalassaemia.

BACKGROUND: Beta-thalassaemia is a hereditary disease, the prevalence of which is high in persons of Mediterranean, African, and Southeast Asian ancestry. In Greece it constitutes an important public health problem. Beta-thalassaemia necessitates continuous and complicated health care procedures such as daily chelation; biweekly transfusions; and periodic cardiology, endocrinology, and hepatology evaluations. Typically, different care items are offered in different, often-distant, health care units, which leads to increased patient mobility. This is especially true in rural areas. Medical records of patients suffering from beta-thalassaemia are inevitably complex and grow in size very fast. They are currently paper-based, scattered over all units involved in the care process. This hinders communication of information between health care professionals and makes processing of the medical records difficult, thus impeding medical research. OBJECTIVES: Our objective is to provide an electronic means for recording, communicating, and processing all data produced in the context of the care process of patients suffering from beta-thalassaemia. METHODS: We have developed - and we present in this paper - Java-based Electronic Healthcare Record (EHCR) software, called JAnaemia. JAnaemia is a general-purpose EHCR application, which can be customized for use in all medical specialties. Customization for beta-thalassaemia has been performed in collaboration with 4 Greek hospitals. To be capable of coping with patient record diversity, JAnaemia has been based on the EHCR architecture proposed in the ENV 13606:1999 standard, published by the CEN/TC251 committee. Compliance with the CEN architecture also ensures that several additional requirements are fulfilled in relation to clinical comprehensiveness; to record sharing and communication; and to ethical, medico-legal, and computational issues. Special care has been taken to provide a user-friendly, form-based interface for data entry and processing. RESULTS: The experience gained through the use of JAnaemia in 4 Greek hospitals reveals a significant contribution towards (1) improvement of the quality of the data being recorded, since data entry is guided by appropriate forms, (2) easier cooperation between physicians, who share a common information repository, and (3) increased processing capabilities, which facilitate medical research. CONCLUSIONS: JAnaemia appears to be a useful tool, which can improve the quality of care offered to beta-thalassaemic patients in Greece.

Greece↗
PubMed1993

Medical audit based on computer-stored patient records exemplified with an audit of hypertension care.

OBJECTIVE: To audit hypertension care at a health centre using computer-based patient records as the source of information and a query language as the analysis tool. DESIGN: Retrospective database study comparing hypertension care in 1989 with hypertension care in 1990. SETTING: One health centre in Sweden with six general practitioners and two doctors on vocational training. PARTICIPANTS: All patients with hypertension in 1989 and 1990. MAIN OUTCOME MEASURE: The percentage of records that complied with the criteria in the hypertension care protocol. RESULTS: 585 records in 1989 and 574 records in 1990 were reviewed automatically by a series of 30 database queries. The computer time needed for the review was eight hours. The first audit showed deficiencies in the management of hypertension, in particular concerning patient history taking and risk factor analysis. The second audit, after the introduction of the hypertension care protocol, showed some minor improvements in the recording and also an increased rate of well treated hypertensive patients. CONCLUSION: Computer-based patient records may facilitate the review of medical records that is needed in medical audit. The audit demonstrates the gap between optimal care and clinical reality.

Humans↗
PubMed2004

Comparison of performance records and national breeding values as input into international genetic evaluation.

The purpose of this investigation was to compare accuracy and precision of variance components and breeding values for international genetic evaluations based on national breeding values or animal performance records. A conventional progeny test scheme was simulated for 3 countries. True breeding values and observations were generated specific to production environments. Two production environments were considered, and both balanced and unbalanced distribution of production environments over countries were considered. True breeding values for both production environments were generated as bivariate normal deviates, and low (0.70) and high (0.90) genetic correlations between performance in production environments were considered. Each cow had an observation in one country only. Performance records were generated as the sum of the true breeding value, a contemporary group effect, and a random residual. Eight generations of data were simulated, and the entire simulated data set was used to compare 3 methods for international genetic evaluation: 1) multiple-trait across-country evaluation based on national predicted breeding values of bulls (Mace), 2) international genetic evaluation across country using performance records, and 3) international genetic evaluation across production environment using performance records. Estimated genetic parameters were biased for all models in this study. Genetic correlations between countries were generally more biased for Mace than for the across-country analyses using performance records. Bias in within-country genetic variances was smaller for Mace. Even genetic parameters obtained with the international evaluation across production environment using performance records were biased, despite the fact that this model was closest to the true, simulated model. The root mean square error of predicted breeding values was similar between models for most of the situations considered. The difference between models was largest when the distribution of production environments over countries was unbalanced and the genetic correlation between performance in production environments was low (0.70). Using breeding values obtained with the across-production environment international genetic evaluation based on performance records will increase the response to selection.

Animals↗
PubMedDate not supplied

Materials for interocclusal records and their ability to reproduce a 3-dimensional jaw relationship.

PURPOSE: The purpose of this study was to determine if accuracy and dimensional stability of vinyl polysiloxanes and irreversible hydrocolloids stabilized by a tray used for fixed prosthodontics, removable partial, and complete denture cases are comparable to those of waxes and record rims and if storage time (24 hours or 6 days) affects dimensional stability of the tested materials. MATERIALS AND METHODS: Two waxes, two record rims, three vinyl polysiloxanes, and one irreversible hydrocolloid (alginate) were examined. Three pairs of master casts with measuring steel rods were mounted on an articulator (initial position). Five records were made of each material, and the upper cast was remounted after 24 hours or 6 days so that deviations from the initial position could be measured. RESULTS: Vinyl polysiloxanes reinforced by a stabilization tray were the most accurate materials able to reproduce a settled interocclusal position. Mounting casts (fixed prosthodontics cases) without records gave accuracy similar to wax records. Record rims used for removable partial and complete denture cases produced lesser accuracy than vinyl polysiloxanes and irreversible hydrocolloid stabilized by a tray. Accuracy was not significantly affected by storage time. CONCLUSION: The results show that accuracy of vinyl polysiloxanes and irreversible hydrocolloids reinforced by a tray is superior to that of record rims with regard to the complete denture case and is among the most accurate with regard to the removable partial denture case. For fixed prosthodontics, however, reinforcement is unnecessary.

Alginates↗
PubMed2001

Risk adjusting cesarean delivery rates: a comparison of hospital profiles based on medical record and birth certificate data.

OBJECTIVES: Compare the discrimination of risk-adjustment models for primary cesarean delivery derived from medical record data and birth certificate data and determine if the two types of models yield similar hospital profiles of risk-adjusted cesarean delivery rates. DATA SOURCES/STUDY SETTING: The study involved 29,234 women without prior cesarean delivery admitted for labor and delivery in 1993-95 to 20 hospitals in northeast Ohio for whom data abstracted from patient medical records and data from birth certificates could be linked. STUDY DESIGN: Three pairs of multivariate models of the risk of cesarean delivery were developed using (1) the full complement of variables in medical records or birth certificates; (2) variables that were common to the two sources; and (3) variables for which agreement between the two data sources was high. Using each of the six models, predicted rates of cesarean delivery were determined for each hospital. Hospitals were classified as outliers if observed and predicted rates of cesarean delivery differed (p < .05). PRINCIPAL FINDINGS: Discrimination of the full medical record and birth certificate models was higher (p < .001) than the discrimination of the more limited common and reliable variable models. Based on the full medical record model, six hospitals were classified as statistical (p < .01) outliers (three high and three low). In contrast, the full birth certificate model identified five low and four high outliers, and classifications differed for seven of the 20 hospitals. Even so, the correlation between adjusted hospital rates was substantial (r = .71). Interestingly, correlations between the full medical record model and the more limited common (r = .84) and reliable (r = .88) variable birth certificate models were higher, and differences in classification of hospital outlier status were fewer. CONCLUSION: Birth certificates can be used to develop cesarean delivery risk-adjustment models that have excellent discrimination. However, using the full complement of birth certificate variables may lead to biased hospital comparisons. In contrast, limiting models to data elements with known reliability may yield rankings that are more similar to rankings based on medical record data.

Adult↗
PubMed2004

Selected impressions on the beginning of the electronic medical record and patient information.

OBJECTIVES: To present an overview of early European and American work on Electronic Medical Records and patient information. METHOD: The invited lectures of "pioneers of electronic patient information" given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed. RESULTS: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first computerized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency. CONCLUSIONS: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

Diffusion of Innovation↗
PubMed1990

Nutrition Evaluation Scale System reduces time and labor in recording quantitative dietary intake.

A time and labor cost study was conducted to evaluate two quantitative techniques for recording dietary intake of individuals: the Nutrition Evaluation Scale System (NESSy) and the weighed food record. NESSy, a new computerized method, uses interactive software to prompt and guide participants through the recording of food weights and descriptions. Twelve men and nine women (aged 23 to 36 years, with 11 to 16 years of education) utilized NESSy for 16 consecutive days while residing in a metabolic research unit. Concurrently, food intake was weighed and manually recorded by trained dietary staff. Analysis of variance on data gathered from NESSy showed no statistically significant differences among sex, age, and educational groupings in the time spent using NESSy. NESSy required 1.73 +/- 0.3 minutes (mean +/- SD) to weigh in, weigh out, and record each food item consumed, whereas the manual technique required 8.4 minutes. The reason for the magnitude of time difference between the two methods is that NESSy provides the flexibility of weighing and recording only foods eaten whereas the manual method requires complete entry of all foods served whether eaten or not. Using the Nutrition Evaluation Scale System to record food intake provides savings in time and labor of about 80%.

Adult↗