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Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

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At least 1,153 records · Page 64Linked to original sources
PubMed2003

Medical documentation: the key to providing continuity of care in anemia management for ESRD patients.

Documentation of anemia-related assessments, interventions, and outcomes is an integral component of proper anemia management for patients with ESRD. In addition to promoting vital communication among medical professionals, documentation helps fulfill regulatory, legal, and payer reimbursement requirements, thereby ensuring that nursing contributions to patient well-being are recognized and that access to care is preserved.

Anemia↗
PubMed1992

[Basic requirements of documentation in school preadmission examination].

Health screening, health counselling, promotion of pupils and health reporting are the principal marks of school doctor's precautionary health care examinations. The appropriate documentation form must meet the basic requirements of the pupil, of the medical officer and of the evaluation programme. The general concept is realized in three steps: first, definition of the contents, second, operationalisation of the individual items and third, the definition of conventional documenting.

Child↗
PubMed1992

[Problems and their solutions in preparation of environmental health criteria documents of IPCS].

Problems and solutions in preparing Environmental Health Criteria (EHC) documents for IPCS (International Programme on Chemical Safety) are summarized. Selection of target chemicals, information search, appointment of appropriate drafters, selection and evaluation of data, use of proprietary data, scientific and English editing, organization of international expert meetings, coordination and secretarial works were the important factors in the preparation of EHCs. The elucidation of the process of risk assessment of chemicals in the EHC preparation will be helpful in preparing other criteria documents.

Documentation↗
PubMed1964

THE CDC-CDCR DOCUMENTATION PROJECT.

A progress report on an experiment in mechanized methods for the storage and retrieval of communicable diseases information. The project, supported by National Institutes of Health grants and begun in 1958, is being conducted by the Center for Documentation and Communication Research (CDCR), School of Library Science, Western Reserve University, Cleveland, Ohio, in cooperation with the Communicable Disease Center (CDC), United States Public Health Service, Atlanta, Georgia. Initial phases have been completed. Seventy-seven questions submitted by the CDC Documentation Committee have been searched by CDCR on their GE-225 computer. For seventy-three of the seventy-seven questions, the system responded with at least one appropriate answer. The combined pertinent and peripheral responses totaled 94.7 percent. The file of abstracted literature is being increased preparatory to large-scale testing. Further investigation and evaluation are necessary before the project can be fairly appraised.

Abstracting and Indexing↗
PubMed2003

[Aggression of psychiatric patients--first results of a standardized documentation at the Gabersee district hospital].

After a cluster of severe assaults against our staff we performed a standardized documentation concerning aggressive behaviour of in-patients at the BZK Gabersee, a major District Hospital with a typical spectrum of psychiatric patients. From July 1996 to March 2001 23037 patients were admitted and 1618 cases of aggressive behaviour were documented. About 75% of the patients were males, more than 50% were treated involuntarily. The aggressions were most frequently directed against the nursing staff, severe injuries occurred very rarely. We tried to analyse triggers and the individual motivations of aggressive behaviour. Countermeasures were often aggressive as well (reinforced medication, restraint e.g.). The results are discussed in the context of the literature, approaches to cope with and to reduce aggressions are mentioned briefly.

Adult↗
PubMed2003

Electronic discharge letters using the Clinical Document Architecture (CDA).

Communication between hospitals and general practitioners is often restricted to paper-based discharge letters. In order to meet the growing need for improved data communication between various actors in the healthcare domain, it is necessary to overcome the barriers of software heterogeneity and lack of standards. HL7's clinical document architecture (CDA) is a new tool to exchange clinical documents. In this paper we show how CDA can be used to share electronic discharge letters generated in the hospital information system with general practitioners. Ease-of-use and data security and integrity were the main design principles. Although there still remain technical and organizational issues to be solved, this is a promising method in order to enhance data exchange between hospital and primary care and to move towards an electronic patient record (EPR) crossing institutional borders.

Computer Communication Networks↗
PubMed1992

A tool to document the competence of clinicians to prevent and manage pressure ulcers.

As one way to meet the standards of quality patient care, a new tool was developed to document the clinical competence of healthcare providers in preventing and managing care for patients with pressure ulcers. The "Clinical Competency Tool for Documentation of Pressure Ulcer Prevention and Management" is described as well as suggestions for incorporating its use in the education of healthcare providers.

Clinical Competence↗
PubMedDate not supplied

[Present day problems in the elaboration of documents regulating sanitary-epidemiological safety of children and adolescents].

The drastic urbanization of modern society, the wide use of new teaching methods and programs at the educational establishments, the emergence of new types of pre-school educational institutions (PEI), the change of age-specific composition of children in both PEI and educational establishments require that new documents on the basic types of educational establishments should be worked out. The financing of work into preparing sanitary legislative documents has not been solved so far. In connection with the adoption of the Federal Law "On Technical Regulation", while preparing the technical regulations, society is to guarantee a child the development environment, good growth conditions, including the optimum level of functions.

Adolescent↗
PubMed2004

Self-report and primary care medical record documentation of mammography and Pap smear utilization among low-income women.

PURPOSE: To determine whether self-report of mammography and Pap smear utilization was accurate and to determine whether racial/ethnic differences existed. METHODS: Face-to-face surveys were administered to 314 consecutively selected women over 40 attending two low-income inner-city family practice sites. Medical records were reviewed for documentation of mammography and Pap smear utilization. Level of agreement between self-report and chart review was reported. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. MAIN FINDINGS: Puerto Rican women had lower income levels and were less educated than African-American and non-Latina white women. Self-report of mammograms and Pap smears were higher than medical record documentation. Level of agreement was higher for more recent tests. Negative predictive values for mammography were high (75-95.5%). Lower sensitivity, specificity, positive predictive value and negative predictive value for mammography were seen among Puerto Rican women compared to African-American and non-Latina white women. CONCLUSIONS: High negative predictive values suggest that asking women about mammography use may be an inexpensive, easy intervention in the primary care setting to increase screening among women currently not being screened by increasing conversations between patients and providers to address personal barriers to screening.

Adult↗
PubMed1992

Documentation of experience: preventive medicine for family physicians. The AAFP Commission on Quality and Scope of Practice.

The AAFP, the American Medical Association and the Joint Commission on Accreditation of Healthcare Organizations clearly agree on the principle that privileges should be based on documented evidence of training, experience and demonstrated current competence. Because of the broad nature of the specialty, family physicians will often be required to provide evidence of competence when requesting hospital privileges. The best defense against difficulties in credentialing and our best hope to continue providing the services to our patients for which we are trained are to create and keep current a strong documentation system of personal training and experience.

Accreditation↗
PubMed2005

Document management: one paving stone in the path to EHR.

Reducing the use of paper records through a document management strategy is an essential first step in implementing the electronic health record. Efficient document management can help to decrease claim denials as well as days in accounts receivable-to name only a few benefits.

Accounts Payable and Receivable↗
PubMed2005

Patient perceptions and provider documentation of diabetes care in rural areas.

Measures of effective diabetes management usually include laboratory results and the provider's point of view, omitting the patient perspective. To address this oversight, a descriptive study was conducted to examine congruence between rural patient self-reported and provider-documented information on American Diabetes Association recommended guidelines. Provider medical record information and patient questionnaires were matched for 149 patients with a diagnosis of type 2 diabetes being treated at rural healthcare facilities. Chi-squared testing showed a significant difference (P < 0.05) between patient and provider information in answers to questions on blood pressure and cholesterol testing, eye examination, influenza and pneumovax rates, and diabetic and nutrition education. Patients' perception of diabetes and blood pressure control did not always match documented values. To achieve diabetes control, providers must implement clinical practice guidelines and patients must take an active role in their disease management. Both must communicate effectively. This does not seem to be the case in rural areas.

Aged↗
PubMedDate not supplied

[Use of natural remedies is seldom documented in medical records. There is a risk of overlooked interactions and adverse effects, as a point prevalence study shows].

Use of herbal medicines can result in adverse effects and in interactions with other pharmacological therapies. The hypothesis of the present study was that health professionals overlook use of herbal drugs. Thus, the aims were (i) to examine to what extent hospitalized patient's use of herbal drugs is documented in the files and (ii) to investigate the patients' attitudes concerning effects and adverse effects of herbal drugs in comparison with regular prescription drugs. Eight out of 58 included hospitalized patients in Sahlgrenska University Hospital used herbal drugs regularly before admission, six of which used regular prescribed drugs simultaneously and one of which had the use of herbal drugs documented in the files. The patients considered regular prescription drugs to be more effective and more prone to adverse effects than herbal drugs. In conclusion, health professionals often overlook patients' use of herbal drugs.

Attitude to Health↗
PubMed2006

Documentation and teaching of surgery with an eye movement driven head-mounted camera: see what the surgeon sees and does.

A first proof of concept was developed for a head-mounted video camera system that is continuously aligned with the user's orientation of gaze. In doing so, it records images from the user's perspective that can document manual tasks during, e.g., surgery. Eye movements are tracked by video-oculography and used as signals to drive servo motors that rotate the camera. Thus, the sensorimotor output of a biological system for the control of eye movements evolved over millions of years is used to move an artificial eye. All the capabilities of multi-sensory processing for eye, head, and surround motions are detected by the vestibular, visual, and somatosensory systems and used to drive a technical camera system. A camera guided in this way mimics the natural exploration of a visual scene and acquires video sequences from the perspective of a mobile user, while the oculomotor reflexes naturally stabilize the camera on target during head and target movements. Various documentation and teaching applications in health care, industry, and research are conceivable.

Documentation↗
PubMed2006

Physician documentation essential for accurate coding and billing of excision of skin lesions.

Clear and precise documentation is essential to accurately code and bill for excision of benign or malignant skin lesions. Detailed documentation is crucial for capturing the full allowable reimbursement when the procedure involves more than a simple closure. For each lesion, only one type of removal may be reported, whether it is destruction, debridement, paring, curettement, shaving or excision. If an initial attempt to remove a lesion by a less invasive procedure is immediately followed by a more invasive lesion removal, only the more complex, definitive procedure may be billed. According to the Current Procedure Terminology manual (CPT), an excision of a skin lesion is defined as "full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed." Changes in recent years now allow code selection based on the greatest clinical diameter of the lesion plus the narrowest margin required for adequately excising the lesion, "based on the physician's judgment." According to CPT, the "measurement of lesion plus margin is made prior to excision".

Current Procedural Terminology↗
PubMed2005

Direct comparison of a tablet computer and a personal digital assistant for point-of-care documentation in eye care.

New mobile computing devices including personal digital assistants (PDAs) and tablet computers have emerged to facilitate data collection at the point of care. Unfortunately, little research has been reported regarding which device is optimal for a given care setting. In this study we created and compared functionally identical applications on a Palm operating system-based PDA and a Windows-based tablet computer for point-of-care documentation of clinical observations by eye care professionals when caring for patients with diabetes. Eye-care professionals compared the devices through focus group sessions and through validated usability surveys. We found that the application on the tablet computer was preferred over the PDA for documenting the complex data related to eye care. Our findings suggest that the selection of a mobile computing platform depends on the amount and complexity of the data to be entered; the tablet computer functions better for high volume, complex data entry, and the PDA, for low volume, simple data entry.

Attitude of Health Personnel↗
PubMed2005

Tracking patient education documentation across time and care settings.

Results of a formative evaluation of a patient education documentation system will be presented. Both quantitative and qualitative approaches to data collection are being used. The goal of integrating patient education documentation into the electronic patient record is to facilitate seamless, multidisciplinary patient/family education across time and settings. The system is being piloted by oncology services at The Nebraska Medical Center. The evaluation addresses the usability and comprehensiveness of the system.

Documentation↗
PubMed2006

Using evidence-based knowledge in a nursing documentation system.

Just as Florence Nightingale based her care delivery decisions on the analysis of outcome results, clinical information systems can support evidence-based nursing content and analysis tools to promote the practice of knowledge-driven nursing. This system demonstration will depict how nursing evidence is embedded into an automated assessment and documentation process to achieve immediate results in such areas as:* Compliance with core quality and clinical performance metrics--including skin integrity, nutritional deficits, IV site care and falls risks. * Integration of patient safety measures such as allergy documentation and medication reconciliation. * Reminders about care management initiatives such as completion of advanced directives and promotion of preventive health measures.

Documentation↗