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At least 1,153 records · Page 64Linked to original sources
PubMed1990

The apparent validity of diet questionnaires is influenced by number of diet-record days used for comparison.

The effect of the number of diet records used as the reference data on the apparent validity of a diet history questionnaire was examined using data from 97 participants in the Women's Health Trial feasibility study. Pearson correlation coefficients were computed between the estimates of usual individual intake from the questionnaire and estimates from the mean of three 4-day records obtained over a 1-year period, the mean of the two most recent records, and the record obtained 1 year after the start of the study. The results illustrate that the apparent validity of a questionnaire increases when it is compared with a greater number of 4-day food records. The correlations increased for most nutrients when the baseline food record was included, despite the fact that it was completed at a time not targeted by the questionnaire. These findings suggest that greater effort should be given to obtaining more diet-record days when validating other dietary assessment instruments.

Aged↗
PubMed1990

[Psychologic considerations in the recording of dental anxiety].

The recording procedure is an especially important aspect of the psychologic treatment, since it contributes to the establishment of confidence between the dentist and his patient, and as such is an essential prerequisite to a successful treatment. The article argues that the registration should concern itself with situations and stimuli which have a traumatic character and with the associated learning processes. Furthermore recording of changes in behavior, somatic aspects of anxiety and of the emotional and cognitive aspects of anxiety should be involved. Based on these general requirements, recording of phobias has five main purposes: Firstly, a recording should contribute to a reliable diagnosis or a sufficiently differentiated description of the phobia that one can offer the best possible treatment and prognosis evaluation. Secondly, the recording should ensure that one can evaluate the effects of different types of treatment or the effects of correction of already initiated treatments. Thirdly, recording should contribute to testing the validity of various models of phobia, and by this means attempt to produce new and better hypotheses for the origin of phobias, their extent, treatment and prevention. Fourthly registration should ensure that different recorders and therapists work with as uniform a conception of phobias as possible, (continual calibration). Finally a registration should be of such a nature that it can be incorporated in an epidemiologic study. In addition to the interview method, the article considers the various objective psychologic and physiological instruments available for the registration of components of anxiety and especially dental anxiety. Weaknesses and sources of error in relation to the reliability and validity of these methods are discussed.

Anxiety↗
PubMed1989

A survey of Scottish Health Boards and English Health Authorities. The extent of computerisation in health visiting records.

There is a wide variation in how computer technology has been used with regard to child health records and allied services. A survey of health boards in Scotland was extended to English health authorities (HAs) to ascertain if information was collected from health visitor records for computer analysis. The results showed Greater Glasgow Health Board uses a record which is coded for a computer. Fife Health Board also used part of this system. In England, ten of the individually described health authorities have just or are in the process of redesigning their records for health visitors. There is a wide variation of how computer technology has been used with regard to health visiting. For an overall picture of family and child most records either relied on the manual part of the record or did not require this information to be recorded. Developments in health visiting which try to ensure a service to the family as well as the child would therefore remain hidden or, more worryingly, untouched.

Community Health Nursing↗
PubMedDate not supplied

An inexpensive four channel demodulator for use in recording sleep biodata in the home environment.

An inexpensive four channel demodulator was developed for use with our existing four channel FM recording system to acquire sleep biodata in the home environment. The demodulator uses four Phase Lock Loop (PLL) circuits for demodulation with capture frequencies selected from the standard IRIG Proportional-Bandwidth FM subcarrier frequencies. Four channels (EMG, EEG and two EOG) may be recorded for six hours at the subject's/ patient's home on a standard 7 1/2 inch reel audio recorder; it may be played back the following day through the demodulator and recorded on a standard laboratory polygraph for subsequent scoring and analysis. The portable home sleep recording system is inexpensive to build (our cost, excluding development, was $160.00); it would be useful to sleep researchers and clinicains interested in comparing sleep in the home versus sleep in the lab, and allows recording of sleep in patients who are reluctant or unable to have their sleep recorded in a laboratory setting.

Electroencephalography↗
PubMed1994

Quality evaluation of patient records in Swedish dental care.

The purposes of this study were to evaluate systematically five patient records each from randomly selected dentists in different regions of Sweden in 1992, and to see whether the good knowledge of some record-keeping rules, noted earlier, was reflected in practical observance of the rules as a whole. Observance was generally poor: in nearly 40% of the variables investigated, the documentation did not follow the rules. Patient history, status, diagnosis, therapy plans and other important information were often missing among the records from the general practitioners. The specialists' records, however, were in general very accurate. As a whole, Swedish dental patient records constitute poor antemortem material for forensic odontology. The dentist's age is related to the quality of the records. The standard of the patient records must be improved.

Adult↗
PubMed1994

General practice patient records.

OBJECTIVE: To examine the management and use of patient records as well as plans for future information management. SETTING: General practice in South Australia (68% response, n = 315). METHODS: Descriptive and analytical cross-sectional study using a mail questionnaire. RESULTS: The sample was representative by age, gender and postcode location of practice. Half the GPs used index cards and 5% computer-based records. Users of the RACGP folder were most (92%) and index card users least (65%) satisfied. The use of patient summaries could be improved. GPs planned to change to computer-based billing, more comprehensive paper-based records, and computer-based patient records. Perceived reasons for and obstacles to change were documented. Factors that influenced the use of different forms of patient records were type and place of practice, staff employed, gender, a Diploma in Obstetrics, age, year of graduation, type of record used and satisfaction with it, vocational registration, FRACGP, and FMP training. CONCLUSION: Given the high use of index cards, a variable but generally low satisfaction and planned changes, there is an unmet need for useful patient record systems in general practice. The effect of affluence of suburb and vocational registration warrants further study.

Cross-Sectional Studies↗
PubMedDate not supplied

Maintaining confidentiality of computerized medical records.

One of the most basic medical values is the sanctity of the doctor/patient relationship and the confidentiality of the communication between the physician and the patient. Another important medical tradition is the production and maintenance of an accurate medical record. In today's health care market, the needs of the payers, the providers and the patients have driven the development of the computerized patient record. the primary advantage of a computerized medical record is the ability to store vast amounts of information and handle the data more efficiently. Such speedy access to data can benefit patient care, but it also threatens the patient's privacy and right to confidentiality. Security of the computerized record poses more of a challenge than protecting the traditional paper chart. There currently is no comprehensive federal legislation dealing with the privacy of a citizen's electronic medical record. It may be necessary to sacrifice some individual privacy in order to receive the benefits of a computerized record. Risks to this confidentiality are many, but can be generally, but not totally, controlled. Acceptable responses to these threats combine technological and practical measures. It is the provider's responsibility to inform his patients of the limitations of security measures and to warn them of the potential threats to maintaining confidentiality of the medical record.

Confidentiality↗
PubMed1995

A clerking tool for the patient record system.

1. BACKGROUND. The goal of the PEN&PAD (Elderly Care) project is to develop a patient record system to assist the many different professionals that care for patients in a hospital setting. At the core of the project is the use of structured data which can be reused in a variety of ways--both within the system for further manipulation and display, and externally for auditing and statistical purposes. To accommodate these needs, a compositional method of data entry called Structured Data Entry (SDE) was used in this application. SDE was developed in an earlier project PEN&PAD (GP)(1). Our application utilizes a network representation of the medical semantics that can be queried to obtain what is sensible to "say" about a particular concept. This functionality is contained within a separate application known as the Terminology Server (TeS), which has been developed within the GALEN project (2). The client application (the patient record system) requests information from the TeS which can then be used to produce compositional data entry forms that require the user to choose values for given attributes (e.g., if information pertaining to chest pain were being recorded, the attribute 'location' and a choice of possible values i.e., 'left' 'right' and 'bilateral' might appear on the form). Given the importance of capturing clinical information in a highly structured format, SDE is a valuable tool. However, its long term success depends on a very comprehensive model of the medical terminology corpus. This component is currently being studied by the GALEN team. 2. CURRENT WORK. We are developing a clerking tool to be used to create records for the newly admitted patient. The clinician seeks to identify a patient's problems based on physical examination and information obtained through conversation with the patient. Patients are usually admitted with a presenting complaint and obtaining more information about this complaint is an important part of the clerking process. While the physician may be able to use the clerking data to consider possible diagnoses right away, he/she often needs to review relevant body systems before a diagnosis is made. In traditional paper based clerking systems, notes are highly formalized but still subject to variation between clinicians. A typical clerking records information such as: 1) history of the presenting complaint; 2) previous medical history; 3) review of body systems; 4) medication; 5) social history; and 6) investigations. We have attempted to retain this clerking outline as much as possible, focusing primarily on the presenting complaint and review of body systems sections. To begin the clerking process, the user chooses a presenting complaint (from the list provided) to launch the 'clerking' window. Access buttons for the different clerking sections are positioned above a data entry window. This window contains a form for collecting information on the presenting complaint. The form is divided into sections to allow the user to record the absence or presence of an associated symptoms and other details. Free text comments can be added to the window, and a data display area shows information entered so far. The user can query the body system database by choosing a system from a menu. At this point the presenting complaint window is replaced by one on the body system in question. The user is free to switch back and forth between the presenting complaint and body system screens. On returning to a previously visited window, the user may pick up where he/she left off when exiting the window. Once the clerking is completed, the information is entered as a unit into the patient record with the date and clinicians name attached. Thereafter, the file becomes read-only. We are currently putting a prototype clerking system through field trials with clinicians from of a local hospital. In our demonstration, we hope to elaborate on these trials and their outcomes.

Admitting Department, Hospital↗
PubMed1995

Use of telephone recording devices by poison centers in the United States.

To determine the extent of and rationale for the use of telephone recording devices by poison centers, a survey was distributed to 93 poison centers in the US during September 1991. Of the 62 respondents, 23 (37%) utilized and 39 did not utilize a telephone recording device. Telephone recording devices were primarily installed to address liability concerns followed by use for quality assurance, staff evaluation and training. The most frequent reason for not using a telephone recording device was the high cost and lack of funds (19) followed by considering it an unnecessary practice (8) and liability concerns (7). Poison centers certified by the AAPCC were more likely to record telephone conversations (p < 0.05) and accounted for 70% of centers with a recording device. A telephone recording device is employed by 1/3 of poison centers primarily to address liability concerns.

Data Collection↗
PubMed1977

Inexpensive technique to record respiration during flight.

This paper describes the development and use of a small (19 X 11 X 18 cm) tape recording system designed to monitor respiratory patterns during flight. This lightweight system (1.85 kg) was developed for less than $200 using commerically available subassemblies. Respiratory patterns are detected via a comfortable intranasal thermometer, amplified, and converted to an FM signal for taping. The device will also convert the tape recorded signal to a graphic display on a laboratory strip chart recorder. Reliable recordings of respiratory rate and respiratory regularity have been made in ambient temperatures of up to 43 degrees C. Chart recordings of student pilots' respiratory patterns at different stages of flight are presented. With modifications to the transducer assembly and amplifier, the basic recording system may be used to monitor other biological functions such as EMG, GSR, EEG, and ECG. Environmental variables have a frequency of less than 250 Hz (wind velocity, temperature, noise, etc.) may also be recorded with proper transducers.

Aerospace Medicine↗
PubMed1996

Medical records and access thereto.

Medical records are essential tools in the practice of medicine. They are important in the planning and monitoring of patient care and for the protection of the legal interests of patients, hospitals and doctors. There is a legal duty on doctors to maintain confidentiality and failure to do so may result in an action for invasion of privacy, defamation or even breach of contract. There are, however, exceptions to this rule. There are procedural remedies available to obtain access to medical records where they are relevant to civil or criminal proceedings. There are also constitutional provisions under the Interim and Working Draft Constitutions which may allow such access. The former only applies to records held by the state while the latter applies to both state and privately held records. Ownership of medical records usually vests in the doctor or institution treating the patient, but such ownership is custodial rather than absolute. Patient records should be accurate, objective and contemporaneous. The international trend is to allow patients to inspect their records and to allow them to make copies thereof. It is submitted that given the provisions of the Interim and Working Draft Constitutions the same should apply in South Africa.

Confidentiality↗
PubMed1996

[Medical records audit in primary care clinics of the Israel Navy].

The primary care clinics of the Israeli Defense Forces are similar to those of the civilian health system, yet some characteristics are unique: Soldiers are a young, healthy population; their physicians are either serving in the reserves for short periods, or are primary care physicians of the regular army; and during military service the soldier is usually treated in several different primary care clinics. A detailed medical record facilitates communication between the various primary care physicians. As part of a 2-year quality assurance project all naval clinics in Israel were surveyed at 6-month intervals. From the clinic records, 685 encounters involving the 7 most common problems were randomly chosen. We evaluated the quality of the medical records of these encounters scoring them according to subjective, objective assessment and therapeutic and evaluative plan (SOAP) Each record was evaluated by 2 physicians and scored from 0 to 100, using fixed criteria. The score for the therapeutic and evaluative plan was significantly higher than that of the other parts of the medical record (80% vs. 55-59%, p < 0.001). The score of the primary care physicians was significantly higher than that of physicians of the reserves (73% vs. 63%, p < 0.001). Encounters involving upper respiratory tract infections and abdominal pain scored higher than those involving other common problems. The medical recording process has a fundamental role in medical care. Our findings suggest that the subjective, objective and assessment parts of naval medical records need improvement. Further studies might help improve the quality of primary medical care.

Humans↗
PubMed1997

Epilepsy and the law-medical records.

This paper reviews the need to keep medical records and concludes that Section 126 of the New South Wales Medical Practice Act, 1992, requires such provision to comply with adequate "professional conduct". This was above and beyond other possible mandatory maintenance of appropriate records, such as may be covered by the notifiable diseases provisions of the Public Health Act. Ethical codes of conduct imposed further obligations to maintain appropriate records, and legal defence against claims of misconduct or negligence required documented evidence to refute false accusations. The emphasis of records has changed with greater need to stipulate risk exposure associated with proposed treatments and advice provided for such things as necessary follow-up. It was further shown that appointment diaries, extra file entries and indications of any failed attendance and resultant subsequent actions were all part of adequate record-keeping. Finally, the paper reviews ownership of medical records and refers to the New South Wales case of Ms Breen, in which it was found that ownership of records, as at the printing of this paper, resided with the doctor.

Disease Notification↗
PubMed1997

[Record linkage of the elderly in the national surveys on the geriatric intermediate care facility].

Geriatric intermediate care facility, GICF, have been established since 1986 in Japan. The term of 'intermediate' denotes a facility midpoint between a hospital and home, with a powerful rehabilitation function. The annual governmental survey on GICF has been applied to all GICFs in Japan since 1989. This survey is a cross-sectional-type survey. For evaluating the role of GICF, we considered a type of cohort study using these surveys for four years by means of a record linkage method. This method is possible, because subjects of a survey for any year become subjects in the survey of the following year, if they have been in a GICF for more than one year. In this paper, for the purpose of preparing for a study of the role of GICF, we report some results about a record linkage for these surveys, and two continuing rates were calculated for these cohorts. Sources were personal records in 1989 to 1992 gathered by The National Survey on GICF in Japan. The record linkage method is as follows. We divided the annual personal records into several files by both the periods of the last admission and the survey year. Three cohorts, i.e. a cohort-89, a cohort-90 and a cohort-91 for persons for whom the first survey was 1989, 1990 and 1991, respectively are thus obtained. Next, we identified individuals from the annual files in each cohort. As personal names were not available, we identified individuals by sex, birth date, date of admission and facility number by the use of a personal computer and a FORTRAN program. Results were as follows. 1. Multiple matched persons were few (0.5% or less), and identification rates were 90% or more, despite the fact that basic linking variables were used. 2. Continuing rates were about 40% and decreased with new cohorts, while those of a fixed cohort were increased as length of stay increased. These reveal that recent admissions who stay continuously at a GICF were decreasing, but the longer the period for which the elderly stays at a GICF, the less possibility that he will be discharged. 3. Between record agreement rates for individuals over two years for unchangeable characteristics such as a place before admission which are expected to be 100% were about 80%. 4. A record linkage method appears to be useful for calculating continuing rates classified by any attribute.

Aged↗
PubMedDate not supplied

[Quality control of nursing records].

Nursing records are one of the main sources of information about the status of patients admitted to intensive care units. In spite of its importance, this information is not always written down. The objective of this study was to analyze the level of compliance and content of sections related with nursing records, overall and by shifts. A retrospective analysis was made of 14 variables in 358 nursing charts chosen randomly, involving a total of 1.075 shifts. The study variables analyzed were: 1) monitoring, 2) medication, 3) losses, 4) nursing incidents, 5) cures, 6) changes, 7) pressure sores, 8) physical therapy, 9) respirator recordings, and 10) nurses' comments (classified by content into 11) systems, 12) priorities, 13) personal observations, and 14) duplication of information. Nursing records related with medical therapy had a significantly better compliance than records of nursing activities per se. When the variables were analyzed by shifts, the only statistically significant variable was nurses' comments. Systems being the modality most frequently used. We conclude that nursing records, which inform us of the patient's status, showed a good level of compliance. Records of therapeutic medical activities were of better quality than those directly related with nursing activities per se.

Critical Care↗
PubMed1998

A tagging system for section headings in a CEN standard on patient record.

CEN is developing a series of standards for transmission of patient records. We present here preliminary results to produce a standard on section headings in record systems. Each record system uses its own scheme of headings, depending on specialty, National regulations and tasks; users cannot accept a unique, standard scheme. Enumerating all possible headings in all National languages is not necessary for a safe and faithful transmission of records. The focus of CEN standard is shifting from the headings to a system of tags that can be tied to them. We want to convey just the crucial properties to assure correct data handling by receivers. Our tagging system is organized into 5 clusters: C0 Nature, i.e. tags to identify the nature of data; C1 Safety context, i.e. essential tags that convey the main context of data; C2 Interpretation, i.e. tags about interpretation of data in the original context by the original user; C3 Intention, i.e. additional tags to make explicit the links that reveal sender's intentions and goals; C4 Organization, i.e. further tags to show the organization of the original record. Although tags were conceived for messages, they should be present in local systems since data generation. In fact, tags can be used to organize data within a record and allow for multiple views, without imposing a unique, fixed structure to the record.

Humans↗
PubMed1979

The problem-oriented system and record keeping in the behavioral therapies.

The Problem-Oriented System (POS) provides systematic guidelines for health care record keeping. Behavioral therapy records share, with health care records in general a quality of inadequacy for contemporary needs. Likewise, behavior therapy training shares with other health care training inadequate attention to record-keeping. This conclusion arises from a search of recent journals and books concerned with behavior therapy issues. This article reviews the POS and proposes that is guidelines and advantages are suited for incorporation into behavioral therapy training. The expected result of such training should be records more amenable to audit or review for such purposes as third party payment, supervision, and peer review. Research is needed to help select the record-keeping training methods that would best meet these contemporary needs for increased quality in the documentation of health care provision.

Ambulatory Care↗
PubMed1980

Patient access to records: tonic or toxin?

The authors review their experiences in permitting psychiatric patients to read their own records. Patients are permitted to read the records with a staff member present to explain the information in the record. Copies of the records are not provided, nor is the patient always provided access to the complete record. Permitting this type of limited patient access to records has resulted in a generally positive experience for the patients, and harm has not ensued.

Adult↗