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 1,495 records · Page 83Linked to original sources
PubMed2006

Evaluation of documents that integrate knowledge, terminology and information models.

Healthcare depends on evidence for practice and for electronic exchange of clinical patient information. To standardize the information that is being exchanged we created a format for describing care related information: a care information model. This model integrates knowledge, terminology and an information model. During a meeting between experts on nursing, standards and electronic patient records we evaluated the format of the care information model by use of an evaluation form and a group discussion. In general, the experts were enthusiastic about the format of the care information model. However they missed specific information about the purpose of the documents, and clarity on copyright issues. In addition, detailed comments on the existing structure and suggestions for additional categories were given. Also, experts suggested representing the integration in both HL7 message model format and in OpenEHR archetype format to allow different implementations of the same intelligence. From this we can conclude that the combination of these aspects in one document creates a valuable content for development of messages and systems. However, some adjustments are needed.

Evaluation Studies as Topic↗
PubMed2006

Using standardized terminology for nursing documentation.

The documentation of nursing data is one important part of compiling information about patient care. Information recorded by using standardized and coded terms is needed to facilitate the subsequent use of nursing data. Structured data can be used to describe, compare and support nursing practice, research, education and management. The possibility of narrative text must also be included in documentation. The Finnish Classification of Nursing Interventions (FiCNI)Ensio A. & Saranto K.: The Finnish Classification of Nursing Interventions (FiCNI) based firmly on the Home Health Care Classification has been tested and used since 2003 in one Central Hospital and two Health Care Centers.

Finland↗
PubMed2006

A language classifier that automatically divides medical documents for experts and health care consumers.

We propose a pipelined system for the automatic classification of medical documents according to their language (English, Spanish and German) and their target user group (medical experts vs. health care consumers). We use a simple n-gram based categorization model and present experimental results for both classification tasks. We also demonstrate how this methodology can be integrated into a health care document retrieval system.

Germany↗
PubMed1990

["Implant"--software for the documentation of statement and course in the special dentist hour consultation of implantology].

A programsystem is presented which supports the attending physician on entering symptoms of clinical and paraclinical parameters. The system runs on personal computer with Z-80 CPU under dBASE II. The program consists of six parts: 1. simple patient data, 2. oral documentation, 3. diagnostical base program, 4. sketch of therapeutics, 5. dispensaire documentation. It aims on the reduction on routine work (e. g. data in- and output) and simple statistical analysis (view of success of several implantationsystems).

Dental Implantation↗
PubMed1990

[Orthopedic documentation and computer technology].

The growth of the volume of necessary information and documentation in the field of health care puts ever increasing demands on its processing. The author presents the method of processing fundamental documentation of an orthopaedic unit by means of computer technology. He also presents the principles for the development of a specific PC software.

Humans↗
PubMed1990

[Computer-assisted documentation and performance data processing in the intensive care unit. Description of a custom development].

Computer-aided documentation of medical and performance data processing seems to be imperative for every intensive-care unit in the future. It is the rational approach to deal with therapy-related information management as well as organizational and administrative tasks. This custom-made program is based on data collected from 3600 intensive-care patients. It serves 3 objectives: 1. documentation of relevant therapeutic data, 2. information exchange with other departments, 3. thorough analysis of topics related to intensive-care medicine. Based on a microsoft disc operating system, the programme contains not only the data base but also word processing and statistical capacities. Optional choice by menu guarantees easy handling and helps to create a high acceptance.

Germany, West↗
PubMed1990

Nurses' documentation about pressure ulcers.

Documentation in a patient's medical record is a nurse's legal and professional responsibility. Descriptive charting about pressure ulcers is critical since it may affect treatment modalities. The purpose of this research was to examine what nurses chart about pressure ulcers. The IAET Standards of Care Dermal Wounds: Pressure Ulcers (1987) was used as a guide. Nursing notes from 167 medical records were examined. None of the nurses' notations contained 100 percent of the items examined in this study. The most frequently occurring descriptor was location (74.2%). This research documents deficiencies in nurses' charting about pressure ulcers.

Aged↗
PubMed1990

The natural history of pancreatic pseudocysts documented by computed tomography.

The clinical courses of 75 patients with pancreatic pseudocysts documented by computed tomography (CT) were retrospectively reviewed. History, physical examination, laboratory findings and CT scan data were analyzed. The treatment regimen followed during the period spanning the review dictated nonoperative management for those patients with asymptomatic pseudocysts who were able to tolerate oral intake. Operative management was used only for patients with persistent abdominal pain or enlargement or complications of pseudocyst. Approximately one-half of the patients (n = 36, 48 per cent) were managed nonoperatively, and the remainder (n = 39, 52 per cent) were treated operatively. In the group managed nonoperatively, with a mean follow-up period of one year, 60 per cent had complete resolution of the pseudocyst documented roentgenographically, and 40 per cent had pseudocysts that remained stable or decreased in size. Only one pseudocyst-related complication developed in the nonoperative group. No pseudocyst-related mortality occurred in either group. The size of the pseudocyst was a significant predictor of the need for operative drainage. Pseudocysts greater than 6 centimeters in diameter required surgical treatment in 67 per cent, significantly more frequently (p less than 0.05) than the 40 per cent of patients who required operative treatment for pseudocysts less than 6 centimeters in diameter. We conclude that a large proportion of patients with pancreatic pseudocysts, without specific indications for operative treatment, can be safely managed nonoperatively, with careful clinical and roentgenographic follow-up study.

Acute Disease↗
PubMed1990

Evaluation of photographic methods for documentation of lens opacities.

Several systems have been developed to document lens opacities photographically. In general, the settings for these photographs have been standardized, but there has been no scientific basis for the selection of these settings. We investigated several of these variables. We examined the effect of degree of angulation of the slit beam in slit photography of the nucleus and found no difference in the grading of nuclear opacities in paired photographs taken with illumination angles of 30 or 40 degrees. Similarly, we found no difference between black-and-white and color film in the detection or grading of either cortical or posterior subcapsular opacities in retroillumination photographs and no difference if a Neitz or an Oxford cataract camera was used. In view of the equivalence of these methods, we would advocate, for reasons of ease of application and cost, the use of a single-color slit-lamp photograph with a 30 degree slit angle for documenting nuclear opacities, and the use of black-and-white retroillumination photography with either the Neitz or Oxford cataract cameras for cortical and posterior subcapsular opacities.

Adult↗
PubMed1990

[A formalized patient history--a new form of medical documentation].

In a work, the characteristic of a new form of medical documentation--formalized case record (FCR), which permits to obtain the detailed information about the state of a patient at all the stages of treatment, is given. Because of the more and more wide introduction of a computer into the clinical practice, FCR can be considered as a necessary form of medical documentation. The universal character of a FCR permits to use it at different in-patient departments of surgical profile.

Computer Systems↗
PubMedDate not supplied

A case of Pneumocystis carinii in pleural fluid with cytologic, histologic and ultrastructural documentation.

Pneumocystis carinii involvement of the pleural cavity in a patient with the acquired immune deficiency syndrome was documented by cytologic as well as scanning and transmission electron microscopic study of pleural fluids. Histologic examination of the pleura and the subpleural lung revealed vasculitis and infarctlike necrosis as well as P carinii in the tissue. Although a few cases of extrapulmonary P carinii infection have been reported, this appears to be the first time its presence in pleural fluid has been documented.

Acquired Immunodeficiency Syndrome↗
PubMed1989

The office diagnosis and documentation of common knee problems.

In this article, I have presented the office physical examination of the knee, emphasized the implication of these physical tests as they relate to primary and secondary restraints, and reported on the preliminary work of the International Documentation Committee (ESKA-AOSSM). A standardized method of physical examination and documentation will assist in the evaluation and critique of our results, and will provide the methodology to compare our results with others.

Humans↗
PubMed1989

[Acetylsalicylic acid in the treatment of arterial thromboembolytic diseases. 2. Clinical documentation].

A review of the literature is undertaken to account for the current status of acetylsalicylic acid (ASA) in the treatment of patients with arterial thrombo-embolic conditions. Employment of ASA monotherapy has been documented to be effective in clinically controlled investigations in patients with unstable angina pectoris, transient cerebral ischaemia, coronary by-pass and femoro-popliteal endarterectomy and introduction of vascular prostheses and, in addition, in primary and secondary prophylaxis of acute myocardial infarction (AMI). In combination with dipyridamol, ASA has been found to be effective in secondary AMI prophylaxis, coronary by-pass operation and in peripheral arteriosclerosis. In patients with cardiac valvular prostheses, conventional anticoagulation therapy must still constitute the basic treatment but dipyridamol may be employed to increase the antithrombotic efficacy of the treatment. The dosage of ASA in the majority of works has been about 1,000 mg daily while isolated investigations have shown good effect from doses as low as 60 mg daily. It appears to be important for the efficacy of the treatment with platelet inhibitors in the above-mentioned conditions that treatment is instituted rapidly and, in connection with operative intervention, preferably preoperatively. In other clinical conditions such as preeclampsia, hypertension in pregnancy, diabetic angiopathy and nephropathy, membranoproliferative glomerulonephritis and arterio-venous shunts with haemodialysis, treatment with ASA appears to be effective but documentation in extensive clinically-controlled investigations is not yet available. The duration of treatment with ASA in arterial thrombo-embolic disease does not appear to be illustrated unanimously in the articles published but, as the atherosclerotic lesion is not influenced by ASA, there are indications for life-long therapy.

Aspirin↗
PubMed1989

[Brief review of documents with data on the toxicity and hazards of chemical substances developed in various countries].

Nowadays various information documents on toxicity and danger of chemical substances exist, i. e., toxicologic certificates, data profiles, trade certificates, etc. An attempt has been made to analyze 15 available data lists used in various countries for the description of noxious and hazardous characteristics of chemicals. The indices on toxicity and danger of chemicals enumerated in the lists are grouped by 9 main categories. The degree of detailed description of the data presented is determined by the aim of the document. The results thus obtained can be used in the further work aimed at the improvement and unification of the forms providing the data on toxicity and danger of the chemicals.

Canada↗
PubMed1989

[The medical and vaccination card for children--a document for the promotion of primary preventive care in pediatrics].

The basis of a comprehensive approach to prevention of chronic diseases of childhood is a system of uniform preventive examinations which makes it possible to examine the child in the parent's presence. This system accentuates the systematic training of parents with the aim to promote health and prevent the development of chronic disease. Part of the effort to improve the health consciousness of parents is the newly developed document, the child's health and vaccination card. This card--contrary to the basic documentation of the child--is his property and is kept by his parents at home. The card provides the parents as well as class teacher with basic information on the child's health status. This information must be used by the parents and teachers for primary preventive regime provisions. By issuing these cards to all children it will be possible to do away with examinations, necessary so far, in conjunction with issuing of certificates on the child's health status before major sports contents. This will reduce the unproductive administrative work of health community doctors and health community paediatric nurses and will save the time of parents who accompanied the children attending these examinations.

Child↗
PubMed1989

[Cause od death statistics and death certificate documentation. 1. Historical development of cause of death statistics of fetal death, infants and children and current regulations in the GDR].

After having described the beginnings of documentation and statistics of causes of death of newborns and children the development of this branch of medical statistics in the GDR and the introduction of a special death certificate in 1961 is dealt with. To help obstetricians, perinatologists and pediatrists to tackle the problem of documentation of the causes of death of stillborns and newborns the 9th revision of ICD, the nowadays valid death certificate and special rules of signing are explained to avoid mistakes, which are often met with in the daily practice.

Cause of Death↗
PubMed1989

Variations in the gait of normal children. A graph applicable to the documentation of abnormalities.

The goal of much orthopaedic treatment of children is to improve their walking. To document the quantitative characteristics of walking, we devised graphic displays of speed, cadence, stride length, and body height on the basis of 2,416 observations of 324 children walking over a range of speeds. The gait graph is an uncomplicated tool for the clinician to use in the documentation and evaluation of gait in children. It also provides the means to relate the walking abilities of patients to the standards for normal children.

Child↗