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 1,387 records · Page 77Linked to original sources
PubMed2004

Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation.

OBJECTIVE: A gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems. DESIGN: This approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification. RESULTS: The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system. CONCLUSION: Using the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge.

Asthma↗
PubMed2006

The clinical document architecture and the continuity of care record: a critical analysis.

Health care provides many opportunities in which the sharing of data between independent sites is highly desirable. Several standards are required to produce the functional and semantic interoperability necessary to support the exchange of such data: a common reference information model, a common set of data elements, a common terminology, common data structures, and a common transport standard. This paper addresses one component of that set of standards: the ability to create a document that supports the exchange of structured data components. Unfortunately, two different standards development organizations have produced similar standards for that purpose based on different information models: Health Level 7 (HL7)'s Clinical Document Architecture (CDA) and The American Society for Testing and Materials (ASTM International) Continuity of Care Record (CCR). The coexistence of both standards might require mapping from one standard to the other, which could be accompanied by a loss of information and functionality. This paper examines and compares the two standards, emphasizes the strengths and weaknesses of each, and proposes a strategy of harmonization to enhance future progress. While some of the authors are members of HL7 and/or ASTM International, the authors stress that the viewpoints represented in this paper are those of the authors and do not represent the official viewpoints of either HL7 or of ASTM International.

Computer Communication Networks↗
PubMed1988

Surgically documented response to intraperitoneal cisplatin, cytarabine, and bleomycin after intravenous cisplatin-based chemotherapy in advanced ovarian adenocarcinoma.

Thirty-one evaluable patients with stages III and IV invasive ovarian adenocarcinoma were treated on a phase II protocol of second-line intraperitoneal cisplatin, cytarabine, and bleomycin. All 31 patients received first-line intravenous (IV) cisplatin-based chemotherapy; the size of the residual cancer was documented surgically before intraperitoneal chemotherapy in all patients. Response to intraperitoneal chemotherapy was documented by a third-look laparotomy in all patients not evidencing progression of disease clinically. There were eight responses (26%): five surgical complete responses and three surgical partial responses. Responders were patients with stage III ovarian cancer, small residual disease of less than or equal to 1 cm (primarily less than or equal to 5 mm), and patients who previously had responded to cisplatin-based IV chemotherapy. Of the 15 patients with stage III ovarian cancer, residual disease less than or equal to 1 cm, and those who had responded to first-line IV cisplatin-based chemotherapy, 53% (eight) responded to second-line intraperitoneal chemotherapy. Intraperitoneal chemotherapy as used in this phase II protocol would appear to be an effective second-line treatment in advanced ovarian cancer in this specific subset of patients.

Adenocarcinoma↗
PubMed1996

Home documented monitoring of cardiorespiratory pattern and oxygen saturation in healthy infants.

The objective of this study was to establish longitudinal normative limits for home memory monitors during early infancy. Eighty-eight healthy infants were monitored overnight at 0.25-19 wk of age using the Healthdyne Smart Monitor. Apnea settings were 14 s for recording and 40 s for alarm; the bradycardia setting was 50 beats/min (5-s delay) for both recording and alarm. Arterial oxygen saturation (SaO2) was documented whenever an event was recorded. The monitor was used 77% of all possible days; median daily use was 8.0 h. Eighty-three percent of all monitor alarms were caused by loose leads, the other 17% by false apnea or false bradycardia. Of all recorded events, 68.9% were caused by false apnea or false bradycardia; the other 31.1% were central apneas that reached the recording threshold of 14 s. The longest apnea was 36 s (wk 1); the 95th percentile for longest apnea was 19.9 s in wk 1 and 18.0 s in wk 17-19 (p < 0.001). Periodic low SaO2 values occurred with periodic breathing; the lowest value was 72%. The 5th percentiles for lowest SaO2 were 82 and 86% in wk 1 and 13-19, respectively (p < 0.001), but the minimum value observed in any week was never > 81%. The median duration of SaO2 < 90% was only 5 s but the range was wide (1-183 s), and 39/527 episodes (7.4%) were > 10 s. In summary, these longitudinal data provide the first available normal limits for cardiorespiratory pattern and SaO2 during documented home monitoring in early infancy. Utilization of these normative data will improve the diagnostic validity and clinical usefulness of event recordings.

Apnea↗
PubMed2003

Evaluation of the American Cancer Society's breast cancer-related documents by cancer survivors.

BACKGROUND: In an attempt to address the informational needs of female breast cancer survivors, the American Cancer Society (ACS) develops and distributes written documents. Although this educational effort has been well received, little attention has been given to the suitability of the materials themselves. METHODS: A random sample of 812 survivors was derived from callers to the ACS National Cancer Information Center (NCIC) from July to December of 2000. The participants then rated the three most commonly distributed breast cancer information documents on five dimensions 1). presentation, 2). satisfaction, 3). understanding, 4). anxiety, and 5). impact. RESULTS: . Participants responded favorably to four of the five rating categories. Conclusions. The evidence suggests that the three materials had positive health outcomes and were well received by the survivors.

American Cancer Society↗
PubMed1998

A longitudinal study of patients with venous malformations: documentation of a negligible hemorrhage risk and benign natural history.

BACKGROUND: The natural history of cerebral venous malformations has not been well documented, and the clinical significance of these common lesions remains controversial. OBJECTIVE: The objective of this study was to follow longitudinally the clinical course of patients with cerebral venous malformations to document the natural history of the lesion. METHODS: Ninety-two patients with radiographically confirmed venous malformations were entered into the study between 1987 and 1996. Annual follow-up was maintained by clinic visits and/or phone interviews. Sixty-three patients (25 men and 38 women) with more than 1 year of follow-up were analyzed. McNemar's test and logistic regression analysis was applied to prevalence of presenting symptoms over time. An average per patient follow-up of 4.2 years yielded 2,721 retrospective and 301 prospective lesion-years for analysis. RESULTS: Average age at diagnosis was 39.1 years (SD, 18.7 years; range, 2 to 73 years). The most frequent lesion locations included the frontal lobe (55.6%, n=35) and the cerebellum (27%, n=17). The most frequent presentations included headache (50.8%, n=32), focal neurologic deficits (39.7%, n=25), and seizure (30.2%, n=19). Prevalence of headache (p=0.048) and seizure (p=0.016) decreased over time without treatment of the lesion. A second cerebrovascular lesion was identified in 12 patients (19%). Two patients had a symptomatic intracerebral hemorrhage attributable to their venous malformation. Risk of hemorrhage was 0.15% per lesion-year (95% CI, 0.06 to 0.38%). CONCLUSIONS: This study establishes that the natural history of venous malformations is benign, that the risk of hemorrhage from these lesions is negligible, and that conservative therapy is warranted.

Adolescent↗
PubMed2000

Documented head injury in early adulthood and risk of Alzheimer's disease and other dementias.

BACKGROUND: The association between antecedent head injury and AD is inconsistent. OBJECTIVE: To examine the association between early adult head injury, as documented by military hospital records, and dementia in late life; and to evaluate the interaction between head injury and APOE epsilon4 as risk factors for dementia. METHODS: The study had a population-based prospective historical cohort design. It included men who were World War II Navy and Marine veterans, and were hospitalized during their military service with a diagnosis of either a nonpenetrating head injury or another unrelated condition. In 1996 to 1997, military medical records were abstracted to document the occurrence and details of closed head injury. The entire sample was then evaluated for dementia and AD using a multistage procedure. There were 548 veterans with head injury and 1228 without head injury who completed all assigned stages of the study. The authors estimated risk of dementia, specifically AD, using proportional hazards models. RESULTS: Both moderate head injury (hazard ratio [HR] = 2.32; CI = 1.04 to 5.17) and severe head injury (HR = 4.51; CI = 1.77 to 11.47) were associated with increased risk of AD. Results were similar for dementia in general. The results for mild head injury were inconclusive. When the authors stratified by the number of APOE epsilon4 alleles, they observed a nonsignificant trend toward a stronger association between AD and head injury in men with more epsilon4 alleles. CONCLUSIONS: Moderate and severe head injuries in young men may be associated with increased risk of AD and other dementias in late life. However, the authors cannot exclude the possibility that other unmeasured factors may be influencing this association.

Aged↗
PubMed2006

Anatomic dissection and classic three-dimensional documentation: a unit of education for neurosurgical anatomy revisited.

OBJECTIVE AND IMPORTANCE: Despite development of computer-assisted neurosurgical navigation, learning by dissecting anatomic specimens is still important. CLINICAL PRESENTATION: We describe the processes from preparation of specimens for cranial dissection to documentation of three-dimensional (3-D) stereoscopic pictures, particularly focusing on the latter, which has been initiated in the Microneuroanatomy Laboratory, Department of Neurological Surgery, University of Florida. INTERVENTION: Preparation consists of irrigation of the major vessels and injection of colored silicone. The 3-D documentation, obtaining two pictures corresponding to each eye's view, is obtained by the shoot-shift-shoot method using a single camera mounted on a slide bar. The key of this method is correct shifting of the camera without alignment error to get exact 3-D effects. Observation of 3-D image can be made with free viewing, a 3-D viewer, or projection. Tips concerning all of the processes involved are described. CONCLUSION: The presented method of dissection and obtaining 3-D images is beneficial for accomplishing studies of anatomy and for providing teaching method.

Dissection↗
PubMed2006

Documented subacute stent thrombosis within thirty days after stenting with sirolimus-eluting stent (Cypher) for acute myocardial infarction: a Japanese single center retrospective non-randomized study.

BACKGROUND: The incidence of subacute stent thrombosis (SAT) within 30 days after stenting with a sirolimus-eluting stent (Cypher) for acute myocardial infarction (AMI) was retrospectively compared to that with bare-metal stents (BMS). METHODS AND RESULTS: Among 559 lesions in 558 consecutive AMI from April 2003 to February 2006, the incidence of documented SAT after Cypher implantation (2/276 lesions, 0.72%) was almost the same as for BMS (2 cases, 0.71%). Aspirin (81-100 mg/day) plus ticlopidine (200 mg/day) were administered continuously after admission in all 4 cases. CONCLUSION: Documented SAT did not increase after stenting with Cypher for AMI under aspirin plus ticlopidine.

Aged↗
PubMedDate not supplied

Nurses' documentation of infection control precautions: 1.

Inadequate nursing records may contribute to untoward incidents and yet advised precautions for the control of infection can be poorly documented. The infection control nurse must promote a safe environment for the patient and ensure that an effective control policy is carried out. The literature suggests that nurses may lack the necessary knowledge and skills with which to assess, plan and evaluate appropriate care for safe infection control. This article, the first of two parts, discusses these issues together with various strategies at the infection control nurse's disposal that may influence nursing practice and the documentation of care.

Clinical Competence↗
PubMed1994

The adequacy of screening, documenting, and treating the diseases of substance abuse.

In a large inner-city teaching hospital, only 28 percent of over 1000 consecutive hospital admissions received proper screening for diseases of substance abuse. Although the CAGE questions are currently considered the best screening test for quickly assessing an alcohol abuse history, not a single CAGE question was documented during our 23 day study. Of the 1010 patients in the study, 160 or 16% were found to be substance abusers. Of these, 57 (37%) were properly screened by the physician team and 8 (5%) received adequate follow-up treatment for their substance abuse by way of social service or psychiatric consultation, or documented counselling by their physician. Physicians are not adequately screening for the diseases of substance abuse, and are not appropriately evaluating and referring patients who are known to be substance abusers. Meaningful training of medical students and physicians is necessary to increase awareness and produce positive behavior change.

Humans↗
PubMed2003

User satisfaction survey and usage of an electronic desktop document delivery service at an academic medical library.

In June 2000, the Biomedical Library at the University of South Alabama introduced Prospero, an electronic desktop document delivery service. From June 2000 to November 2002, Prospero delivered 28% of interlibrary loan requests and 72% of document delivery requests. In November 2002, the library conducted a user satisfaction survey of the Prospero service. Forty-two surveys were used. Fifteen responses were received from affiliated faculty, staff, and students, who generally expressed satisfaction with the service. Twenty-seven responses were received from unaffiliated users, comprised of medical libraries, individual users, and businesses. Based on the survey results, the library deemed the Prospero service a success. To better support users, the library's Web page was updated to include hardware and software requirements for successful use of the Prospero service, as well as screen shots of the Prospero process.

Alabama↗
PubMed1993

Bronchodilator reversal of bronchospasm and symptoms incurred during methacholine bronchoprovocation challenge. Documentation of safety and time course.

We undertook a prospective study of bronchoprovocation challenge (BPC) to look at issues of safety and reversibility of bronchospasm and symptoms induced by BPC. Over a 14-month interval, we documented 62 consecutive cases of bronchial hyperresponsiveness. During BPC, there was a statistically significant but clinically modest increase in both cough and dyspnea. Both bronchospasm and symptoms were readily reversed with a simple protocol of inhaled albuterol using a metered-dose inhaler with a spacer. Routine protocol was effective in every case; there was never a need for individualized physician intervention. Our prospective data document the safety of BPC; we could find no reason why BPC would need to be confined to the hospital. We conclude that BPC is a valuable clinical test which merits wider dissemination and use.

Adolescent↗
PubMed2001

Evaluating, documenting and following up oral pathological conditions. A suggested protocol.

BACKGROUND: Many textbooks and articles are available to assist dentists in examining patients, establishing diagnoses for oral lesions and understanding the techniques of biopsy. There is little guidance in the literature, however, on when and how to follow up lesions that have a low index of clinical suspicion, or for which the pathological diagnosis does not demonstrate any overt signs of malignancy or premalignancy. TYPES OF STUDIES REVIEWED: The authors reviewed the literature, talked to numerous clinicians and sought legal opinions regarding how a reasonable and prudent dentist should manage patients with clinically evident oral lesions that do not suggest any adverse long-term effects on the health and safety of the patient. RESULTS: The few guidelines available in the literature, coupled with the observations of the authors and others, allow logical and reasonable interim recommendations to be proposed regarding the frequency of examinations, the timing of invasive procedures and medicolegally prudent documentation guidelines. Future studies are needed to refine these recommendations. CLINICAL IMPLICATIONS: Some dentists have been sued for alleged failure to monitor patients, document cases or refer patients with oral lesions. The recommendations provided here can help dentists manage these patients, but they should not be construed as being rigid guidelines or legal standards that apply to all clinical situations. In some cases, the judgment and experience of clinicians may indicate the need to deviate from these recommendations. Refinements of these guidelines may emerge on the basis of future studies.

Biopsy↗
PubMed2004

The electronic immediate discharge document: experience from the South West of Scotland.

BACKGROUND: Communication and transfer of information between healthcare professionals are essential to a seamless healthcare process, and are vital for ensuring that there is smooth transition of care for patients. Throughout the National Health Service (NHS) Scotland, there is a wide variability in the quality and quantity of information provided in the immediate discharge document (IDD). AIMS: To analyse general practitioner (GP) attitudes and responses on the quality and efficacy of an electronic IDD (e-IDD). SETTING: All GPs in Dumfries and Galloway. METHODS: GPs communicating electronically with the hospital were sent a survey questionnaire at the end of an 18-month pilot. An amended questionnaire surveying potential interest was sent to the remaining GPs in the region. RESULTS: The overall response rate was 70%. Eighty-one percent of practices connected received the e-IDD regularly, but the majority still used it in conjunction with its postal equivalent. Seventy percent complained of inadequacies in content relating to medication and follow-up information. Eighty percent agreed that it was faster and 68% felt significant cost savings could be made. Eighty-eight percent wanted a multidisciplinary input. Concerns were raised about funding, need for adequate training and back-up systems. Ninety-six percent were optimistic that in future other forms of clinical communications could be sent electronically. CONCLUSION: Discharge content is more important than delivery method. Emphasis should be placed on ensuring standards are met on the quality and quantity of current e-discharge documents. Further clarification is required on patient confidentiality issues and legal validity of electronic patient records. E-health is to play a larger and ever-increasing role in the NHS in Scotland.

Attitude to Computers↗
PubMed2006

Learning from technical documents: the role of intermodal referring expressions.

OBJECTIVE: We investigated the impact of two types of intermodal referring expressions on efficiency of instructions for use. BACKGROUND: User manuals for software or technical devices such as a video recording system frequently combine verbal instructions and illustrations. Much research has shown that the presence of an illustration has a beneficial effect on learning. The present study focuses on a factor that modulates this beneficial effect. The combination of text and an illustration can be effective only if the user integrates the information coming from these two media. This integration depends largely on the intermodal referential expressions, the function of which is to mark explicitly the relations between the text and the illustration. METHOD: In an experiment (N = 104), we compared the effectiveness of two intermodal referring expressions often used in procedural texts: indexes (numbers introduced in the illustrations and in the instructions to establish cross-references) and icons (visual representations of the components of the device, which are inserted in the verbal instructions). RESULTS: The icons condition led to the most efficient use of the device. CONCLUSION: This experiment shows that learning from multimedia documents depends on the possibility of effectively connecting the verbal instructions to the illustration. APPLICATION: Taking into account the ergonomic properties of the cross-media referring expressions should allow text designers to improve the effectiveness of technical documents.

Belgium↗
PubMed2004

[Consenting to ambiguities: a documental analysis of informed consent forms used in assisted human reproduction clinics].

With the field of assisted human reproduction as a case study, this article presents the results of a study on informed consent forms, linking the understanding of the use of social languages - especially the language of risk - and its implications on the relationship between health professionals and clients. Informed by a social psychology perspective and aligned with the qualitative tradition in research, the study was oriented by a theoretical approach to discursive practice, whereby the language of risk is understood as a way of speaking of future control of risks. The analysis centered on the text of 27 informed consent forms provided by eight Brazilian clinics. Besides understanding the linguistic specificities, the analysis attempted to answer the question, "What is being consented to?" The results showed the ambiguity of a document which presupposes the use of the metaphor of taking versus not taking risks. That is, the document may be used in a democratic, bureaucratic, or even authoritarian way, while the communication of risks and benefits subsidizes both the decision-making and the dilution of responsibility throughout the relational network.

Decision Making↗
PubMed2007

Clinical importance of carbapenem hypersensitivity in patients with self-reported and documented penicillin allergy.

The risk of carbapenem hypersensitivity in patients with self-reported or documented penicillin allergy needs to be determined so that practitioners can make better-informed decisions regarding antibiotic therapy for this patient population. The risk of cross-reactivity between penicillin and carbapenem antibiotics initially was reported to approach 50%. Recent retrospective studies have suggested that the clinical risk of cross-hypersensitivity between these two drug classes is 9.2-11%, which is significantly lower than initially reported. Patients whose history of penicillin allergy is self-reported and is not type 1 may be at moderate risk for hypersensitivity when treated with a carbapenem antibiotic. The risk of hypersensitivity appears to be higher in patients whose penicillin allergy was documented by a health care provider, those with several antibiotic allergies, and those with a positive penicillin skin test result or a history of type 1 penicillin hypersensitivity.

Anti-Bacterial Agents↗