Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “DOCUMENTATION”

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.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,369 records · Page 76Linked to original sources
PubMed2006

[The "Seville" Consensus Document on Alternatives to Allogenic Blood Transfusion. Sociedades españolas de Anestesiología (SEDAR), Medicina Intensiva (SEMICYUC), Hematología y Hemoterapia (AEHH), Transfusión sanguínea (SETS) Trombosis y Hemostasia (SETH)].

The Consensus Document on Alternatives to Allogenic Blood Transfusion (AABT) has been drawn up by a panel of experts from 5 scientific societies. The Spanish Societies of Anesthesiology (SEDAR), Critical Care Medicine and Coronary Units (SEMICYUC), Hematology and Hemotherapy (AEHH), Blood Transfusion (SETS) and Thrombosis and Hemostasis (SETH) have sponsored and participated in this Consensus Document. Alternatives to blood transfusion have been divided into pharmacological and non-pharmacological, with 4 modules and 12 topics. The main objective variable was the reduction of allogenic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi method, which classifies the grade of recommendation from A (supported by controlled studies) to E (non-controlled studies and expert opinion). The experts concluded that most of the indications for AABT were based on middle or low grades of recommendation, "C", "D", or "E", thus indicating the need for further controlled studies.

Aminocaproic Acid↗
PubMed1992

[Computer-assisted patient management. Individual electronic data processing-assisted documentation in gynecology].

EDP-supported documentation of patients has become increasingly important over the last several years. Seven autonomous wards of the gynecological department of the Hospital Rudolfstiftung were equipped with a clinical documentation system. The integration of this new system into the infrastructure of the KIS (Krankenhausinformationssystem) was accomplished with the help of the MD-ADV. We also implemented one of the best-known statistical analyzing systems, SAS, so that we have simple possibilities for statistical calculation and graphical plots.

Computer Graphics↗
PubMed2001

G20210A prothrombin gene polymorphism and prothrombin activity in subjects with or without angiographically documented coronary artery disease.

BACKGROUND: G20210A prothrombin mutation has been associated with high prothrombin levels and an increased risk of venous thrombosis. The role of this common polymorphism, as well as that of prothrombin levels, in determining the risk of arterial disease is still somewhat controversial. METHODS AND RESULTS: We determined the prevalence of the G20210A mutation and prothrombin activity in 660 individuals, of whom 436 had angiographically documented severe coronary artery disease (CAD patients) and 224 had normal coronary angiography (CAD-free control subjects). Heterozygosity for the 20210A allele was found in 5.3% of the CAD patients versus 3.1% of the CAD-free subjects (P=0.21). Similarly, no statistically significant difference was found between CAD patients with or without previous myocardial infarction (4.5% versus 5.3%, respectively; P=0.73). The genotype-phenotype correlation study showed a significant influence of the 20210A allele on prothrombin activity, with higher levels in carriers compared with noncarriers (153.2% versus 122.2%, respectively; P<0.001). Prothrombin activity was significantly higher in CAD patients than in CAD-free subjects (132.8% versus 123.3%, respectively; P<0.005). By multiple logistic regression, prothrombin activity in the upper tertile of the control distribution was significantly associated with CAD compared with prothrombin activity in the lower tertile (adjusted odds ratio 1.86, 95% CI 1.01 to 3.4). CONCLUSIONS: In a population with a clear-cut definition of the phenotype, the G20210A prothrombin mutation was not significantly associated, per se, with either angiographically documented CAD or myocardial infarction, whereas it significantly influenced prothrombin activity. In our population, high prothrombin activity itself was independently associated with CAD but not with the presence or absence of previous myocardial infarction.

Aged↗
PubMedDate not supplied

Intracranial embolization via external carotid artery: report of a case with angiographic documentation.

This report describes our experiences with a patient who developed delayed recurrent retinal and hemispheric ischemia distal to an old internal carotid artery occlusion in the neck. Fundoscopy and sequential cerebral arteriography documented that recurrent ischemic symptoms in this individual were the result of embolic fragments arising from the "stump" of the occluded internal carotid artery and from a diseased external carotid artery. These emboli traversed the external carotid artery and its orbital and intracranial anastomotic connections to reach the symptomatic eye and hemisphere. Ischemic symptoms in this patient were effectively terminated with anticoagulant therapy. We believe that this patient graphically documents that post-occlusion microembolism via the external carotid artery does indeed occur, and probably accounts for post-occlusion recurrent ischemic attacks more frequently than is currently appreciated. Recognition of this phenomenon is of importance because of its significant therapeutic implications. In these situations treatment modalities which terminate embolic phenomena would appear to have a more rational basis than do surgical procedures designed primarily to augment collateral blood flow to the symptomatic organ(s).

Arterial Occlusive Diseases↗
PubMed1980

Documenting a shortage of psychiatrists: the repair shop model.

The author presents a model for documenting a shortage of psychiatrists. The model employs efficiency, work load, and work time to determine numbers of psychiatrists needed for a hospital setting. Survey data collected from 900 psychiatrists were used to quantify these variables and to identify possible determinants of variation. Differences in residency training were associated with differences in efficiency. As presented, the model is incomplete and cannot be used to explicity define manpower requirements. The author's discussion expands the model and focuses on the complexity of documenting a true shortage or surplus of psychiatrists.

Foreign Medical Graduates↗
PubMed1997

Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder.

OBJECTIVE: The skepticism regarding the existence of dissociative identity disorder as well as the abuse that engenders it persists for lack of objective documentation. This is doubly so for the disorder in murderers because of issues of suspected malingering. This article presents objective verification of both dissociative symptoms and severe abuse during childhood in a series of adult murderers with dissociative identity disorder. METHOD: This study consisted of a review of the clinical records of 11 men and one woman with DSM-IV-defined dissociative identity disorder who had committed murder. Data were gathered from medical, psychiatric, social service, school, military, and prison records and from records of interviews with subjects' family members and others. Handwriting samples were also examined. Data were analyzed qualitatively. RESULTS: Signs and symptoms of dissociative identity disorder in childhood and adulthood were corroborated independently and from several sources in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10 cases. CONCLUSIONS: This study establishes, once and for all, the linkage between early severe abuse and dissociative identity disorder. Further, the data demonstrate that the disorder can be distinguished from malingering and from other disorders. The study shows that it is possible, with great effort, to obtain objective evidence of both the symptoms of dissociative identity disorder and the abuse that engenders it.

Adult↗
PubMedDate not supplied

ADA-based accommodations in higher education: a survey of clinicians about documentation requirements and diagnostic standards.

The expansion of the number of students requesting accommodations in postsecondary settings compels clinicians to become knowledgeable about the legal definitions and documentation requirements of the Americans with Disabilities Act (ADA). Because the law is relatively new, courts and regulatory agencies have only recently begun to clarify what constitutes a disability. In this study, 147 clinicians completed a questionnaire developed to assess their understanding of the law and the diagnostic approaches they used to justify claims of learning disability (LD), attention-deficit/hyperactivity disorder (ADHD), and psychiatric disability. Whereas the clinicians agreed on certain points (e.g., the right of institutions to formulate specific policies regarding documentation), they substantially disagreed on several fundamental issues. Clinician consensus was lowest on items that asked about the basic intent of the law, the metrics for assessing impairment, and the criteria for assessing ADHD in adulthood. Judged against the legislative history of the ADA and the body of regulatory rulings and legal decisions, many clinicians' responses showed a need for clarification regarding the distinction between special education law and the antidiscrimination intent of the ADA. The respondents also expressed a nearly uniform wish for more training in this fast-growing area of clinical practice.

Attention Deficit Disorder with Hyperactivity↗
PubMed1989

Video documentation of endoscopic sinus surgery.

A simple, reliable technique for videotaping endoscopic sinus surgery is described. This system may be used for teaching purposes and patient education. It may also be used to document pathologic conditions of the sinus as well as for documenting the surgical procedure itself.

Endoscopy↗
PubMed1992

Assessment and documentation of the breastfeeding couple by health care professionals.

Health care professionals have been a major source of conflicting and misleading information about breastfeeding. The role of the certified lactation consultant is to correct this problem. Documentation in the medical record is the primary method of communication between the postpartum nursing staff and the hospital-based lactation consultant. An in-service program oriented staff to the use of a breastfeeding assessment tool which systematized breastfeeding documentation; it also instructed staff in the techniques of completing such an assessment. Charts were audited before and after the program to assess changes in charting practices. Results reflected an increased likelihood of charting objective observations regarding the quality of the breastfeeding relationship.

Breast Feeding↗
PubMed1998

Does your care plan tell my story? Documenting aspects of personhood in long-term care.

Learning about aspects of one's personhood allows the nurse to know the individual as a person and to individualize the care provided. A pilot project was conducted on a supportive residential care unit to explore why health records in long-term care rarely reveal who the person is. Five nurse participants generated a list of features of an individual's personhood that they felt should be known by members of the team. They subsequently gathered that information from a variety of sources, with documentation in a designated location provided on the plan of care. They were thus able to overcome some of the previously encountered barriers to collecting and documenting the personhood data reflecting their knowledge of the individual as a person. Although nurses were successful in learning who the persons were, changes in approach to care as a result of the new knowledge have not been measured.

Aged↗
PubMed2005

Outcomes in acute ischemic stroke patients without angiographically documented arterial occlusion.

BACKGROUND AND PURPOSE: Patients with acute ischemic stroke who undergo emergent cerebral angiography for consideration of intra-arterial treatment and do not have an angiographically demonstrable occlusion pose a management dilemma. The authors reviewed their experience to determine the clinical out comes of patients with ischemic stroke evaluated within 6 hours of symptom onset in whom negative angiograms were obtained. METHODS: A prospective registry was maintained for all patients (N = 56) who were considered for intra-arterial thrombolysis. Patients without angiographic arterial occlusion were not treated with thrombolytics, and data pertaining to clinical characteristics and neuroimaging findings was collected. Follow-up data were acquired through clinic visits or telephone interviews at 5.5 +/- 5.0 months (mean +/- SD), range 1 to 15 months, after onset of stroke. RESULTS: Of the 56 patients, no arterial occlusion was observed in 17 (30%) patients (mean age 65.8 +/- 13.0 years; 7 were men). The mean (+/- SD) baseline National Institute of Health stroke scale score was 10.2 +/- 7.1. Symptoms were referable to the anterior or posterior circulation in 76% and 18% of the patients, respectively; they could not be localized to either circulation in 6%. Follow-up neuroimaging studies demonstrated cerebral infarction in 12 of 14 patients. Eleven of the 17 had a favorable long-term recovery as assessed by the modified Rankin Scale (score 0 or 1). Five other patients had modified Rankin Scale scores of 3 (n = 1), 4 (n = 2), or 5 (n = 2). One patient died during the follow-up period. With regard to location of ischemic deficits, the highest rate of death or dependency was observed in patients with pontine infarction (three of four patients). CONCLUSION: Although the outcome following ischemic stroke in patients without angiographically documented occlusion appears to be better than that reported for patients with angiographically documented occlusion, death or disability is observed in at least one third of the patients. There fore, acute ischemic stroke in the absence of angiographic occlusion is not entirely a "benign" entity and can be particularly devastating when the brainstem is involved.

Aged↗
PubMed1994

Risk factors for acute renal insufficiency in patients with suspected or documented bacterial pneumonia.

OBJECTIVE: To describe the incidence of acute renal insufficiency and identify potential risk factors associated with this adverse medical event. DESIGN: A cohort analytic study of patients with documented or suspected bacterial pneumonia. SETTING: Nationwide survey of 74 acute care hospitals across the US. INCLUSION AND EXCLUSION CRITERIA: A total of 1822 adult patients with documented or suspected bacterial pneumonia who were receiving a cephalosporin, penicillin, or an aminoglycoside were enrolled. Patients were excluded if the duration of antimicrobial therapy was < 3 days or if the pneumonia was judged to be nonbacterial. DATA COLLECTION: Clinical pharmacists completed standardized data collection forms on all patients enrolled in the study. Information regarding patient demographics, concurrent illnesses and medications, antibiotic administration, representative laboratory data, and the occurrence of any adverse clinical event was specifically captured. Information regarding the development of acute renal insufficiency was targeted as an event to be captured. MAIN OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify significant risk factors for acute renal insufficiency. A subset analysis was similarly performed to identify risk factors associated with aminoglycoside-related acute renal insufficiency. RESULTS: Of the patients enrolled in this study, 8.2 percent developed acute renal insufficiency. Risk factors for acute renal insufficiency included renal disease, aminoglycoside therapy, nosocomial pneumonia, elevated estimated creatinine clearance prior to study entry, cardiac arrest/shock, congestive heart failure, total duration of antibiotics > 7 days, clindamycin therapy, liver disease, and first-generation cephalosporin usage. Risk factors for aminoglycoside-related acute renal insufficiency identified via multiple logistic regression included amphotericin B, congestive heart failure, aminoglycoside trough concentration > 1.5 mg/L, and clindamycin therapy. CONCLUSIONS: The risk factors identified for acute renal insufficiency suggest that severity of illness strongly influences the development of renal insufficiency. Theoretically, the results of this study could serve as a framework for developing risk prevention programs within individual hospitals. Specific risk factors could be identified for a patient population and risk factors that could be modified could then be targeted for intervention. This type of information can also assist clinicians in predicting the probability of the adverse event for a particular patient and subsequently minimizing this risk by initiating intense monitoring or modifying the drug regimen.

Acute Kidney Injury↗
PubMed1981

A roentgenographic technique to evaluate and document hindfoot position.

The position of the posterior portion of the foot is difficult to evaluate and document on the basis of clinical examination. Conventional roentgenographic techniques also do not allow objective determination of hindfoot position. A new roentgenographic technique utilizing a double-exposure has been developed to allow accurate documentation of the position of the calcaneus relative to the ankle. Normal adult values for this technique have been determined from 60 normal feet.

Ankle↗
PubMedDate not supplied

Looking to CQI for improvements in clinical documentation and coding.

The following paper examines how the philosophy of Continuous Quality Improvement (CQI) can be used to improve the quality of clinical documentation and coding. The philosophical basis of CQI and its application in the healthcare environment is outlined. Health information managers need to explore inventive ways of solving the problem of inadequate clinical documentation and high coding error rates, particularly in light of the current casemix-based funding environment.

Australia↗
PubMed1997

Prevention of Risks from Occupational Exposures to Antineoplastic Drugs: Consensus Document.

Ever-increasing numbers of cancer patients have been treated with antineoplastic drugs in the past few years. Among patients treated with these drugs, an increased risk of a "second neoplasm" has been observed, mainly as a function of increased life expectancy. On the basis of this observation, the International Agency for Research on Cancer has classified a number of antineoplastic drugs as carcinogenic or probably carcinogenic for humans. Various categories of workers are at risk for exposure to antineoplastic drugs, absorbing these substances mainly through inhalation or dermal contact. Although the absorbed doses are notably lower than those administered to patients, review of the literature reveals increased risks of spontaneous abortions and chromosomal aberrations in subjects who have worked without adequate protection. A working group, Prevention of Occupational Risks Due to Handling Antineoplastic Drugs in Health Care, was established by the Italian Institute of Prevention and Safety at Work (Istituto Superiore per la Prevenzione e Sicurezza sul Lavoro-ISPESL) in February 1995. This group reviewed the epidemiologic studies and research on cytogenetic indicators of genotoxicity in occupationally exposed subjects. In addition, the group made recommendations for environmental and biological monitoring of exposure and health surveillance, and developed guidelines for primary and secondary prevention. The group's recommendations are summarized in a consensus document, but cannot be considered definitive, since work practices continue to evolve and will have to be examined further in the future. Thus, more research is needed to achieve answers to the questions raised by the working group. The main topics to be addressed are indicated in the consensus document. In particular, it will be necessary to evaluate working conditions nationwide, using standardized protocols for risk assessment, to achieve precise estimates of workers' exposures.

Journal Article↗
PubMed2005

Automatically annotating documents with normalized gene lists.

BACKGROUND: Document gene normalization is the problem of creating a list of unique identifiers for genes that are mentioned within a document. Automating this process has many potential applications in both information extraction and database curation systems. Here we present two separate solutions to this problem. The first is primarily based on standard pattern matching and information extraction techniques. The second and more novel solution uses a statistical classifier to recognize valid gene matches from a list of known gene synonyms. RESULTS: We compare the results of the two systems, analyze their merits and argue that the classification based system is preferable for many reasons including performance, simplicity and robustness. Our best systems attain a balanced precision and recall in the range of 74%-92%, depending on the organism.

Animals↗
PubMed2003

Animated documentation of the filaria dance sign (FDS) in bancroftian filariasis.

BACKGROUND: Ultrasonography is able to detect adult Wuchereria bancrofti worms in scrotal lymphatic vessels of infected men on account of the characteristic pattern of adult worm movements, known as the filarial dance sign. Furthermore, the technique is able to delineate associated pathology, such as hydrocoele and lymphoedema, which can be diagnosed in early stages. Ultrasonography is also useful in the assessment of macrofilaricidal effects of antifilarial medication.The purpose of this study was to evaluate the usefulness of scrotal ultrasonography, in combination with a new method of digital documentation, in men infected with Wuchereria bancrofti. METHODS: Ultrasonography of the scrotal areas was carried out in 33 male patients from an endemic area in Ghana using a hand-carried ultrasound system and a linear array transducer at 7.5 MHz. Wuchereria bancrofti infection was also assessed by quantification of night blood microfilaraemia and semi-quantitative detection of circulating filarial antigen. Ultrasound findings were documented by print outs and by Digital Video sequences directly exported from the ultrasound machine which were edited in Final Cut Pro 3ledR; and exported, using QuickTimecircledR; Pro, as MPEG-1 video. RESULTS: Worm nests, i.e. dilated lymphatic vessels with the characteristic movement patterns of worms, were found in all patients, and typical examples of larger as well as smaller nests are presented through MPEG-1 video in b- and m-modes as well as Colour Doppler and Pulse Wave Doppler images. CONCLUSION: In this study, the filarial dance sign is being made available on the Internet to readers through MPEG-1 video. This method allows for demonstration of movement patterns rather than static images. In addition, the pathologic ultrasonographic signs of filariasis can be rapidly relayed over great distances and may be helpful to other investigators or clinicians in the diagnosis of patients infected with Wuchereria bancrofti.

Journal Article↗
PubMed2005

Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder.

BACKGROUND: There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers. AIMS: To verify combat exposure history for a relevant sample through objective historical data. METHOD: Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined. RESULTS: Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam 'combat' and 'no combat' groups on relevant clinical variables. CONCLUSIONS: A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

Combat Disorders↗