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PubMed1995

[Classification and documentation of liver metastases of colorectal carcinomas].

Today, there is a variety of therapy modalities for patients with liver metastases. This therapeutic spectrum has made a more accurate classification of liver metastasis necessary. Data concerning therapy have to be documented as well as pretherapeutic data and data concerning results of pathologic examination. Without a careful documentation a reliable comparison between different therapy modalities will be impossible and thus a generally accepted concept of liver metastasis therapy cannot be expected. A classification of liver metastasis thus required should aid in the planning of treatment, yield an indication of prognosis, and assist in the evaluation of the results of treatment.

Clinical Trials as Topic↗

PubMed1994

Institutional and economic influences on quality of nursing documentation.

This study evaluates the quality of nursing documentation within the hospital record for a particularly vulnerable group of patients, the depressed aged. Specifically, the effects of prospective payment, unit type, hospital type, and nurse staffing levels on nursing documentation within hospital charts were assessed.

Aged↗

PubMed1994

Computerized documentation of pharmacists' interventions.

A computerized system for documenting interventions, developed by the pharmacy department at a 695-bed tertiary care university teaching hospital, is described. A computerized system was developed to better gain the needed details on pharmacists' recommendations, to capture a greater number of such recommendations, and to prepare for recent changes in standards of the Joint Commission on Accreditation of Healthcare Organizations. Only clinically important recommendations or those that involve cost savings are documented. Data can be entered and retrieved from any medical information system terminal in the hospital, and each entry becomes part of the patient's permanent record. A hard copy of all recommendations and a data file are generated daily. Analysis of the data has provided numerous opportunities for improving both patient care and the quality of pharmaceutical services. The system has been well received by pharmacists and has resulted in physician support of pharmacists' recommendations, as well as substantial cost savings. A convenient, easy-to-use computerized program for reporting interventions has helped a pharmacy department conduct departmental and institutional quality assurance activities and decrease costs.

Clinical Pharmacy Information Systems↗

PubMed1994

[Primary and secondary interventions--a concept in surgical documentation].

Nowadays systematic documentation of surgical procedures is absolutely necessary in all departments of surgery and will soon be required by law. Therefore code systems are essential. Amongst numerous systems the ICPM-GE classification has been chosen as basis. In the department for abdominal and transplantation surgery at Hanover Medical School the ICPM-GE classification has been extended by a concept of coding main and suboperations. This concept considers the fact that in an individual patient the surgical procedure may consist of different and standardized suboperations. This concept widens and simplifies the possibility of documentation considerably.

Cholecystectomy↗

PubMed1994

Documentation in home health care practice. Evidence of quality care.

Documentation in home care has become an increasingly important part of the nursing role. This article discusses some common problems with the written word encountered by nurses. A research study on documentation done in an urban home care agency is also presented.

Documentation↗

PubMed1994

Using system integration to revise documentation.

Within a 10-month time period, a new system-wide documentation common to five hospitals in the Evangelical Health System was designed and implemented. The documentation system is comprised of the Nursing Admission Assessment, Patient Care Plan, Patient Care Flowsheet, and Patient/Family Education Record. Examples of barriers and success factors as well as the system's framework are presented.

Documentation↗

PubMed1993

Formulation of a systematic method of documentation for nurse-led mental health groups.

This article describes the formulation of a systematic method for the documentation of nursing led mental health groups, from the initial idea and development of the format to utilization of the form "Monthly Group Summary Form for Nursing Mental Health Groups." Although designed by clinical nurse specialists in psychiatric nursing for an inpatient psychiatry site, the development process and the documentation method are adaptable to any venue.

Cognition↗

PubMedDate not supplied

Documentation forms for monitoring occupational surveillance of healthcare workers who handle cytotoxic drugs.

PURPOSE/OBJECTIVES: To develop a procedure for medical surveillance of healthcare workers who handle cytotoxic drugs. DATA SOURCES: Literature review and guidelines published by the Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health. INFORMATION SELECTION: Studies of possible exposure screening tests, congenital defects in offspring, and case studies. DATA SYNTHESIS: Some degree of risk exists in handling cytotoxic drugs, but no reliable screening test for cytotoxic drug exposure has been developed. Reproductive hazards are possible when protective equipment is not used. Areas to be addressed when devising surveillance procedures include who to cover, what baseline data to gather, what periodic monitoring will be necessary (and at what interval it will be conducted), how to handle exposure incidents, and what documentation system will be used. CONCLUSIONS: A procedure using a baseline risk factor form and a yearly monitoring questionnaire was devised and implemented. Forms contain documentation of worker teaching. IMPLICATIONS FOR NURSING PRACTICE: Most often, nurses are the healthcare workers who handle cytotoxic drugs. A consistent approach to monitoring healthcare workers is facilitated by using a defined procedure and standardized forms.

Antineoplastic Agents↗

PubMed1994

Colposcopic documentation. An objective approach to assessing sexual abuse of girls.

Accurate measurements of the genital anatomy of victims of child sexual abuse can be documented with colposcopic photography. Most colposcopies available, however, do not have a built-in measuring grid for medicolegal documentation. Because of the unique optics designed for the colposcope, an accurate comparison can be provided if the measuring tool is photographed in the same focal plane and at the same magnification as the object of concern. Properly labeled slides may then be used as clear evidence in court.

Anthropometry↗

PubMed1993

Changing to computerized documentation--plus!

A recent change to a computerized documentation system has had a positive influence on productivity, reliability of documentation, quality assurance, nurse satisfaction and professional practice. This software system combines the care plan and nurses' notes and is standard-based. Each patient's care plan is compiled from Units of Care, which provide a menu covering nursing diagnosis, medical diagnosis, chief complaints and special procedures and events.

Documentation↗

PubMedDate not supplied

[Collection of relevant data in psychoanalytically oriented inpatient psychotherapy--The Tiefenbrunn Documentation System].

We inform about development of the Tiefenbrunn documentation system for inpatient psychotherapy. Aims and scaffolding of the system and some difficulties to make the system run are outlined. The newly developed instruments are sketched. Patients received a questionnaire concerning their social situation and their family of origin. At the same time therapists indicate symptoms, diagnosis, work ability, prognosis, pretreatments and chronification (diagnosis sheet I) and results of treatment (diagnosis sheet II) when patients leave. During treatment complementary therapy (as e.g. massage etc.) is documented. From 1988 on we have 230 variables on every patient in our computers. Actual and further use of the system is described.

Data Collection↗

PubMed1996

[Individual therapy goals: on outcome documentation of inpatient psychotherapy from the patient and therapist viewpoint].

The results of a study evaluation in practicability of two newly developed documentation forms are presented. Examined are 82 inpatient treatment episodes in an already published clinical concept with different treatment settings. Parallel versions of the forms were completed by patients and therapists. The 'Erge-Doku-A-Form' allows for the naming of up to five therapy goals determined at the beginning of therapy and evaluated in relation to their achieved quality at the end of therapy. The 'Erge-Doku-B-Form' describes a variety of problem areas as well as questions related to medication and changes induced by therapy. Surprising there were a high number of 230 Individual Therapy Goals (ITG) by patients and 262 ITG by therapists which could be arranged into 89 content categories and 5 main categories. Outcome measurement shows different results. There was a significant relationship between the 'well-being', the impression of 'satisfying treatment' at the end of the inpatient period and 'success in the main ITG'. The documentation forms presented here allow an outcome-measurement depending on differential indications.

Adult↗

PubMedDate not supplied

[Problems and possibilities of documentation in the field of analytic psychotherapy].

The article is concerned with the problems of documentation in the field of psychotherapy and psychoanalysis. A report is given about the different ways of documentation which have been used in the Institut for Psychogenic Diseases, Berlin. It is described which facts are important to be recorded, what kind of informations about the patients can be collected without to much bias of the facts, and which kind of theoretical systems will create difficulties if they are used for data collection.

Documentation↗

PubMed1996

[Documentation of treatment and quality assurance: recommendations for a practical solution].

It is proposed to establish an internal quality assurance with a practical care documentation which at the same time will also fulfill the requirements of external quality assurance. A graphically economically designed questionnaire is presented. The integration of the diagnostic standards for child and adolescent psychiatry makes the questionnaire--made concrete for every clinic--usable in a communicably and dialogically external quality assurance. With the example of concrete data from the clinic of child and adolescent psychiatry in the hospital Bremen-East is shown how suitable indicators for quality are included in the care documentation.

Adolescent↗

PubMed1996

[Computer-assisted documentation of mandibular fractures].

For the registration, documentation and evaluation of patient data in cranio-maxillo-facial (cmf) trauma surgery a Windows-based application front end for relational data base systems (RDBS) has been developed. A simple-to-learn, easily reconfigurable user interface can be adjusted to the dynamically changing needs of individual departments. A graphical user interface (GUI) eases the entry of complex information like fracture positions, the location of implanted osteosynthesis material, etc. The new program also simplifies the daily routine documentation tasks. Being linked to a Hospital Information System (HIS) it makes use of the patients' individual base data stored there. Statistical data for various studies can be extracted from the database. The program has been successfully tested on a collective of 1.178 cmf trauma patients. Predefined analyses can be generated now by the simple click of a button for various case selections. New users learn to operate the program in a very short time.

Computer Graphics↗

PubMed1996

Documentation and reimbursement by clinical setting.

Healthcare is a business. As healthcare professionals and clinicians, we must accept this fact. Regulatory issues and reimbursement mechanisms have an enormous impact on the quality of care, the introduction of new technology, utilization of products and services, patient access to care, and the actual outcomes of care delivered. An understanding of these issues is necessary for the wound care clinician who must be adequately reimbursed for his/her services. This Chronic Wound Care Preview gives an overview of Medicare and Medicaid, and reimbursement essentials necessary in the acute care, subacute care, skilled nursing facility and home health care setting. Basic reimbursement tenets, along with wound care documentation guidelines, are discussed. The message is clear: the single, most critical factor to favorable coverage decisions is complete, accurate, and descriptive documentation. It is the clinician's responsibility to educate third-party payers on the cost benefits, safety and efficacy, and positive outcomes of the many treatment and management approaches for wound care.

Case Management↗

PubMed1996

Documenting data delivery: design, deployment, and decision.

Developing and deploying informatics solutions which are useful and acceptable to busy physicians are challenging tasks. We describe the design, deployment, and evaluation process by which the delivery of routine clinical laboratory reports is automated using electronic mail. Data from TMR, an operational computer-based patient record (CPR), are presented to providers using an individualized, modern interface. This system is compared to the existing, paper-based system for delivery of data from the same CPR. Differences between the two systems of data delivery are analyzed, with emphases on 1) electronic documentation of data delivery and receipt, 2) electronic and/or paper documentation of clinical action taken as a result of laboratory reports, 3) timeliness of report availability, 4) costs, 5) workflow compatibility, and 6) physician satisfaction. The new delivery system employs inexpensive, commercially available software applications and entails only trivial changes to the proprietary CPR. Built into the new system are features which allow quantitative measurements of its performance for analysis along with survey-based user satisfaction data. The open systems design is deliberately non-proprietary, inexpensive, and generalizable. Accordingly, it offers practical possibilities for settings in which clinical information systems are just being planned, as well as for those in which such systems are already established.

Clinical Laboratory Information Systems↗

PubMed1996

[Value of computer-assisted sperm analysis (CASA). Reproducibility--online documentation--prognostic value].

Computer-Assisted Semen Analysis (CASA) permits a determination of sperm count and sperm motility, improves reproducibility and facilitates the documentation of the results. In addition, new motility parameters can be measured. An analysis of the CASA parameters of 792 ejaculates revealed that their distribution is similar to that of the sperm count and sperm motility obtained by simple microscopic counting. A comparison of CASA parameters with the subsequent conception rate with the aid of Cox's regression analysis, showed that sperm count and total motility are the sole predictors of fertility. Attempts to measure sperm morphology using CASA have already been initiated. It can be noted that CASA analysis is superior to the simple microscopic evaluation of the ejaculate in its objectivity, reproducibility and on-line documentation. However, it does not increase the significance of semen analysis in terms of fertility prognosis.

Documentation↗