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At least 1,207 records · Page 67Linked to original sources
PubMed1997

Documenting wife abuse: a guide for physicians.

An estimated 12% to 30% of women are assaulted by their male partners at least once during the relationship. Therefore, in their everyday practice, physicians are likely to encounter women who have suffered domestic abuse. The authors define wife abuse, outline epidemiologic aspects and discuss common signs and symptoms. In cases of suspected or confirmed abuse, it is very important for physicians to document the details of the injuries, the patient visit, any treatment and follow-up as well as to screen for associated conditions and ensure that any samples taken are not tampered with. When asked to disclose information by police or courts, physicians need to know when they are obliged to submit copies of their patients' medical records, when patient consent is required, what information should be divulged and how to defend this information in court. The authors present information about the necessary, relevant and appropriate evidence to be collected and documented for both medical and legal purposes. They also discuss the criminal justice system and the role of physicians in legal proceedings concerning wife abuse.

Adult↗
PubMed1998

Inadequate documentation and resection for gastric cancer in the United States: a preliminary report.

Patients entered into Southwest Oncology Group gastric adjuvant protocol INT 0016 (SWOG 9008) after a "curative" gastric resection were assessed to determine practice patterns of more than 300 surgeons nationwide who performed "curative" gastric resections for 453 gastric cancer patients. The most common gastric resection performed was distal in 256 patients, proximal in 118, and total in 79. Extragastric organs resected were omentum (285), spleen (59), pancreas (18), and bowel (17). The extent of lymphadenectomy as staged by Japanese rules was 246 (54.2%) D0 resections, 173 (38.1%) D1 resections, 28 (6.2%) D2 resections, and 7 (1.5%) D3 resections. Staging of the cancer was poorly documented, with no statement made regarding the status of the primary cancer in 6 per cent, liver in 10 per cent, lymph nodes in 17 per cent, and omentum in 17 per cent. The greater the lymph node clearance, the greater the chance of resecting to a level of negative lymphatics, given that 45 per cent of nodes were involved when 10 or less were removed, whereas only 17 per cent were positive when more than 40 were cleared. The lack of adequate clearance of lymph nodes and poor documentation of tumor stage suggests that a more regimented surgical approach to this uncommon cancer is required.

Documentation↗
PubMed1998

From text to knowledge: a unifying document-centered view of analyzed medical language.

Although medical language processing (MLP) has achieved some success, the actual use and dissemination of data extracted from free text by MLP systems is still very limited. We claim that the adoption of an 'enriched-document' paradigm (or 'document-centered' view) can help to address this issue. We present this paradigm and explain how it can be implemented, then discuss its expected benefits both for end-users and MLP researchers.

Artificial Intelligence↗
PubMed1976

[Pictorial documentation in orthopaedics (author's transl)].

The experiences of 60 years of pictorial documentation in an Orthopaedic Clinic are presented. Whereas the evaluation of patient's progress by photographs dominated formerly, nowadays the main interest is frequently centered on scientific illustrations and documentation for teaching, lectures and publications. The paper describes, how these two demands can be met economically by effective utilization of the technical possibilities.

Documentation↗
PubMed2004

Quantitative documentation of a premenstrual flare of facial acne in adult women.

OBJECTIVE: To quantitatively document the presence and extent of a late luteal (premenstrual) acne flare in adult women. DESIGN: Case series. SETTING: Subjects were recruited from a general community dermatology practice and by advertising. SUBJECTS: Adult women 18 to 44 years old with normal periods who were receiving no treatment for their acne. MAIN OUTCOME MEASURES: Acne lesion counts were surveyed over the follicular and luteal phases of 2 full menstrual cycles. RESULTS: Most (63%) of these women showed a 25% premenstrual increase in the number of inflammatory acne lesions. CONCLUSION: This is the first quantitative documentation of the presence and degree of premenstrual acne flares in adult women.

Acne Vulgaris↗
PubMed1996

Use of a pharmacy and medical claims database to document cost centers for 1993 annual asthma expenditures.

OBJECTIVE: To demonstrate the utility of a combined pharmacy and medical claims database in the assessment of the incidence and the cost centers of asthma care in a managed health care system. DESIGN: A retrospective observational study to document annual cost for asthma therapy by cost center during 1993. SETTING: Four affiliated health maintenance organizations. PARTICIPANTS: A total of 25,614 asthmatics identified from a population of approximately 673,000 members in the health maintenance organization. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Annual charges by cost center for asthma care analyzed by age and gender. RESULTS: The period prevalence of asthma was 3.8%. Annual direct medical charges for asthma were $467.40 per member. Inpatient hospital and emergency department charges were greater in children than adults. Adolescent girls had increased use of the emergency department and inpatient hospital facilities and lower charges for medications than their male counterparts. Their increased use of acute care facilities was responsible for 25% greater charges for total asthma care. The gender differences in cost centers continued for adults, with increased charges for inpatient hospital and emergency department charges and lower expenses for medications for women. CONCLUSIONS: Charges for acute care were inversely related to the dollars spent on pharmaceuticals. This study demonstrates the ability of a combined medical and pharmacy database to document the charges for care and possibly identify indicators of undertreated populations.

Adolescent↗
PubMed2000

Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

OBJECTIVE: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. DESIGN: Multi-method, cross-sectional observation study. SETTING: Eighty-four family practices in northeast Ohio. PARTICIPANTS: Four thousand fifty-four outpatients visiting 138 family physicians. MAIN OUTCOME MEASURE: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits. RESULTS: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients. CONCLUSIONS: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.

Cross-Sectional Studies↗
PubMed1991

Noncongenital hereditary hearing loss in children. Prospective documentation.

Younger siblings of children with sensorineural hearing loss of possible hereditary cause underwent interval audiologic examination. Seven siblings (in unrelated families) were found to have progressive sensorineural hearing loss despite early audiograms documenting normal hearing levels for age. Continued testing of these children allowed for early identification and intervention. We advocate regular otolaryngologic and audiologic follow-up even after normal audiologic assessments are made for younger siblings of children with documented sensorineural hearing loss, unless a definite nongenetic origin of the hearing loss in the older child is known. Recessive sensorineural hearing loss with onset in infancy or childhood may present with no antecedent family history and with normal behavioral audiograms early in life.

Audiometry↗
PubMed1987

Albumin lung/heart ratio change. A simple clinical means of documenting increased pulmonary endothelial permeability to protein.

We investigated a simple method that can be used at the bedside for documenting the net accumulation of albumin in the lung. The technique employs measurement with a computer-linked gamma camera of the activity ratio in an area of the right lung compared with the same-sized area in the heart at 20 minutes and three hours following intravenous injection of technetium Tc 99m albumin. We applied this measurement to three groups of patients: a control group and patients with roentgenographic evidence of edema classified according to clinically available criteria as either hydrostatic edema or permeability edema to see if we could document differences among these groups. In control patients this ratio did not increase by more than seven units between the 20-minute and three-hour measurements. Of 18 patients classified by other routine clinical means as having hydrostatic pulmonary edema, 89% showed no increase in lung albumin accumulation. In 29 patients with permeability edema associated with the so-called adult respiratory distress syndrome, 31% showed evidence of net pulmonary albumin accumulation. These findings suggest that some patients otherwise classified as having hydrostatic edema have concomitant permeability changes in the microvasculature and that permeability edema represents a spectrum of endothelial damage.

Capillary Permeability↗
PubMed1989

The Medical Directive. A new comprehensive advance care document.

Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.

Brain Diseases↗
PubMed2001

Documenting and comparing medical students' clinical experiences.

CONTEXT: The decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships. OBJECTIVE: To demonstrate a system that documents medical students' clinical experiences across clerkships. DESIGN AND SETTINGS: Evaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000. PARTICIPANTS: A total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine. MAIN OUTCOME MEASURES: Number of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records. RESULTS: Students completed 86 011 patient encounter cards: 48 367 cards by 582 students in family medicine, 22 604 cards by 469 students in pediatrics, and 15 040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings. CONCLUSIONS: An instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education.

Diagnosis-Related Groups↗
PubMed1998

Documented symptomatic hypoglycaemia in children and adolescents using multiple daily insulin injection therapy.

Symptomatic episodes of documented hypoglycaemia were characterized with the aid of a 3-month diary in a single-centre, unselected group of 161 children and adolescents with Type 1 diabetes mellitus, treated mainly (81%) with multiple-dose insulin therapy. Patients and families were asked to write in the diary all the symptomatic episodes in which blood glucose concentration proved to be < or =3 mmol l(-1) before treatment. Of the patients, 83 (52%) had a total of 287 hypoglycaemic episodes (0.6 attack per month per patient). The majority of the attacks, 221 (77%), were mild (patients > or =6 years able to treat themselves). Only two attacks were severe, resulting in coma and/or convulsion. The most common dominant symptoms were weakness (29%), tremor (20%), hunger (14%), and drowsiness (12%). Of all the dominant symptoms, 39% were classified as autonomic, 20% neuroglycopenic, and 41% non-specific. In children under 6 years, autonomic symptoms were less common than in adolescents 15 years or over (34% vs 57%, p = 0.01). In conclusion, the incidence of documented symptomatic hypoglycaemia was low. The symptoms were more often neuroglycopenic or non-specific than autonomic, especially in young children.

Adolescent↗
PubMed1999

Evaluation of ofloxacin in the treatment of laparoscopically documented acute pelvic inflammatory disease (salpingitis).

OBJECTIVE: To evaluate the safety and efficacy of intravenous and oral ofloxacin monotherapy in the treatment of laparoscopically documented acute pelvic inflammatory disease (PID). METHODS: This study was conducted as an open-label, phase-III, uncontrolled, multicenter study. Patients identified with laparoscopic findings of salpingitis were treated with 400 mg of intravenous ofloxacin every 12 hours followed by 400 mg of oral ofloxacin every 12 hours for 10 to 14 days. Patients were evaluated five times for clinical and microbial efficacy. Since laparoscopy was performed only at admission, pathogens identified laparoscopically were presumed eradicated if they were present on the laparoscopic culture and the patient was clinically cured or improved at final evaluation. RESULTS: Of the 70 patients evaluable for safety (intent-to-treat population), the mean age was 25.6 years. Sixty-one of 70 patients (87%) were cured, one improved, one did not improve, and seven were unevaluable because they discontinued study participation. Fifty-one were evaluable for clinical efficacy: 50 (98%) were cured and one did not improve. Sixteen were evaluable for expanded microbiological efficacy: three had documented Neisseria gonorrhoeae; 12, Chlamydia trachomatis; and one, a mixed infection of both organisms. All cervical, laparoscopic, and endometrial cultured pathogens, including N. gonorrhoeae and C. trachomatis, were eradicated or presumed eradicated at the posttherapy visit. No serious or unexpected adverse events occurred. CONCLUSIONS: Ofloxacin monotherapy was effective and well tolerated in the treatment of laparoscopically proven PID in a geographically diverse population. Future studies are necessary to evaluate long-term outcomes and sequelae of PID treatment with single agent therapy.

Administration, Oral↗
PubMed1996

Improved eating behavior in eating-disordered inpatients after treatment: documentation in a naturalistic setting.

OBJECTIVE: Abnormalities of eating behavior are definitional components of eating disorders (ED), but are seldom observed directly. This study assessed abnormalities of eating behavior in ED patients before treatment and documented changes after multidisciplinary treatment. METHOD: Thirty-three ED patients (13 ANR, 10 ANB, 10 BN) and 10 controls selected a lunch meal in a cafeteria before and after treatment with energy intake (kilocalories) and macronutrients covertly observed. Visual analog scales (VAS) measured hunger and satiety. RESULTS: Before treatment, all ED patient groups experienced low hunger and high fullness, compared to controls. After treatment, hunger increased and satiety decreased. ANR patients, after treatment, increased energy intake from 366 to 916.5 kcal (p < .001), while BN patients increased from 409.9 to 663 kcal (p = .03). ANB nonsignificantly increased. ANR chose significantly more fats (22.7% to 36.2%, p = .05). DISCUSSION: Treatment partially normalizes pre-meal hunger and satiety in ED patients and significantly improves eating behavior (total energy intake and fat content) in ANR and BN patients. Reasons for nonsignificant changes in ANB are not obvious. We recommend documentation of eating behavior by simple, inexpensive, observational methods in a naturalistic setting before and after treatment of ED patients.

Adolescent↗
PubMed2000

Pneumococcal vaccine administration associated with splenectomy: the need for improved education, documentation, and the use of a practical checklist.

An audit was performed of the documentation of pneumococcal vaccination in splenectomy patients in three major hospitals involving a geographical population base of 350,000 patients in British Columbia, Canada. Overall, 111 of the 164 hospitalized splenectomy patients (68%) had received pneumococcal vaccination. Of elective splenectomy cases, only 11 of 55 (20%) had been vaccinated prior to surgery, as is currently recommended. One hundred fifty-five patients (95%) had splenectomy status mentioned in the discharge summary. However, only 35 (21%) had mention of vaccination status, 10 (6%) mention of the need for future revaccination, and only 8 (5%) notation of the possibility of future infectious risks. The rate of pneumococcal vaccination was as satisfactory as any reported in the literature to date. However, there is need for improved education in relation to the timing of vaccination and discharge summary documentation. A checklist for potential splenectomy patients may aid in improving this situation as may geographically based splenectomy registries.

Adolescent↗
PubMed1980

Effective treatment of hormonally-unresponsive metastatic carcinoma of the prostate with adriamycin and cyclophosphamide: methods of documenting tumor response and progression.

Combination chemotherapy with Adriamycin and cyclophosphamide was administered to 22 men with progressive tumor following hormonal treatment for metastatic carcinoma of the prostate. Objective partial response was documented in 7 patients (32%); an additional four (18%) had stable disease for a minimum of four months, and 11 (50%) were non-responders. Patients with partial response had a median survival of 14 months and lived significantly longer than those with no response (median five months); survival of men with stable disease approximated that of partial responders. Serial utilization of multiple staging procedures during chemotherapy demonstrated that although no single test allowed identification of all patients with objective tumor response or progression, improvement in median of five parameters could be documented in responding patients. In patients adequately studied at the time of disease progression, deterioration in a median of six tests was found. Serum acid phosphatase radionuclide bone scan, and plasma carcinoembryonic antigen were the most sensitive procedures which detected both objective tumor response and progression. Toxicity of chemotherapy was acceptable except in patients with prior radiation therapy. Administration of Adriamycin and cyclophosphamide was associated with clinical benefit in half of our patients with hormone-resistant prostatic cancer. Tumor response and progression can best be objectively assessed if several staging procedures are serially employed during treatment.

Aged↗
PubMed1990

Autopsy-documented cure of multiple myeloma 14 years after M2 chemotherapy.

Multiple myeloma was diagnosed in a 65-year-old woman in 1974 who thereafter received five-drug M2 chemotherapy. All protein abnormalities subsequently returned to normal and serial bone marrow studies documented complete bone marrow remission. Destructive bone lesions persisted radiographically, but did not progress. In 1987, a localized sigmoid adenocarcinoma was resected. In 1988, the patient presented with multiple brain metastases associated with a primary pulmonary adenocarcinoma that proved rapidly fatal. At autopsy, no evidence of multiple myeloma was found. This report describes the first tissue-documented cure of multiple myeloma 14 years after diagnosis and initiation of M2 chemotherapy. The possible association of multiple myeloma with other malignancies is also discussed.

Aged↗