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At least 1,531 records · Page 85Linked to original sources
PubMed1995

Testing Orr's document delivery test on biomedical journals in South Africa.

This paper describes the use of a document delivery test (DDT) to measure the availability of biomedical research journals in South African health sciences libraries. The methodology employed was developed twenty years ago by a team of researchers from the Institute for the Advancement of Medical Communication under the direction of R. H. Orr. The testing of the methodology was in itself an objective of the present research. A citation pool consisting of 307 items was constructed from references to journal articles in papers published in 1989 by South African biomedical researchers. The availability of each article was determined at each of seven medical library sites; the performance was measured and presented as an arithmetical value or document delivery capability index (CI). The results of the tests show a high level of availability, ranging from CI = 81.68 to CI = 92.97 for the journals sampled. The DDT methodology was found to be practical, applicable to such studies, and flexible. Its use is recommended for similar studies.

Information Systems↗
PubMedDate not supplied

Using a clinical pathway approach to document patient teaching for breast cancer surgical procedures.

PURPOSE/OBJECTIVES: To develop a tool suitable for documenting patient teaching regarding surgery for breast cancer. DATA SOURCES: Standards of care, clinical experience, published articles. DATA SYNTHESIS: Development of a clinical pathway approach to documenting patient teaching was a logical outgrowth of a hospital-wide effort to implement pathways. CONCLUSIONS: After use and revision, the nursing staff at Leonard Hospital determined the tool to be a comprehensive approach to patient education and it became a permanent part of the patient record. IMPLICATIONS FOR NURSING PRACTICE: The tool provides a standardized approach for teaching patients who are having breast cancer surgery and can be used in a variety of care settings by all members of the healthcare team.

Breast Neoplasms↗
PubMedDate not supplied

Eliminating friendly fire. Successful nursing documentation strategies.

Often, an institution's documentation policies, procedures, and records become frustrating instruments of torture rather than helpful resources for the nurses who must use them. In this article, the authors highlight several of the strategies used by one nursing service department to eliminate barriers to adequate documentation.

Attitude of Health Personnel↗
PubMed1994

Does your documentation defend or discredit?

Documenting medical records is often done hurriedly; it is a last responsibility before the patient is discharged, sometimes after the shift has actually ended. What seemed so clear at the time it was written may be barely legible, unbelievably incomplete, and perhaps legally indefensible later. The patient's chart is a permanent legal record that can powerfully defend or easily discredit the nurse when questions arise. A documentation review could be time well spent.

Humans↗
PubMedDate not supplied

Archiving requirements for electronic pharmaceutical manufacturing documents and associated executable software.

Many pharmaceutical manufacturers are currently evaluating the feasibility of electronic batch record (EBR) and electronic document management (EDM) systems. Considerable effort has been invested in the design of the batch record files and electronic signature devices and procedures. Much less consideration has been given to the potential need for pharmaceutical manufacturers to be able to re-create the operational software environment necessary to review archived documents at some future date. The paper discusses methods, policies, and equipment that can be used to fulfill this function.

Archives↗
PubMed1994

[Measuring and documentation of edema].

Measuring and documentation of peripheral edemas should be carried out consistently both in ambulant and in hospital treatment. It's technical easy and can be done as measuring of circumference or of volume. This documentation is important both for the doctors and the physiotherapists and the patients too.

Anthropometry↗
PubMed1994

Administering, documenting, and tracking blood products and volume expanders.

A quality improvement program designed to facilitate the administration, tracking, and documentation of blood products and volume expanders resulted in improved patient safety, improved efficiency, more accurate documentation, and enhanced resource management. Key to the success of the program were the Transfusion Administration Record, the blood product administration guide, and on-line transfusion history recording.

Blood Transfusion↗
PubMed1994

Microlevel documentation: relational database for critical path development.

There have been great strides in developing hospital information systems (HISs); however, there are few if any systems that are fully integrated to allow nursing documentation at microlevel data--that is, information about interventions between a nurse or other health care disciplines and the patient. It consists of the data used by a nurse in taking care of patients at the intervention level. This article suggests a process for developing a fully integrated HIS that will build a nursing minimum data set (NMDS) to aid in case management systems development, costing-out services, and nursing research. The goal of the system is to decrease the amount of paperwork, allowing the nurse to spend more time with the patient, and at the same time improving the quality of documentation and improving patient outcomes.

Cost-Benefit Analysis↗
PubMed1994

Putting care on the record. Documenting nursing care in outpatient departments.

1. The role of outpatient nurses will need to change from facilitators to care givers. 2. Outpatient nursing documentation must be easy to complete and guided by the primary need of each patient group. 3. Outpatients must take responsibility for self-care. 4. Care plans have a dual role--as nursing documentation and as patient information or reference for care.

Ambulatory Care↗
PubMed1993

The patient problem/nursing diagnosis form: a computer-generated chart document.

The INFORMM (Information Network for Online Retrieval & Medical Management) patient problem/nursing diagnosis form is a computer-generated, patient record document of information related to identified patient conditions and patient outcomes. These patient and nursing data, accessible online as well as in paper copy, enhance continuity of care by providing, to all authorized clinicians, a list and history of identified patient problems/nursing diagnoses and the patient's status in terms of the achievement of projected patient outcomes. This cumulative, patient-centered documentation facilitates patient care effectiveness and provides mechanisms to capture and retrieve patient and outcome data for quality improvement and research purposes.

Computer Systems↗
PubMed1993

An ODA-based coder/decoder for multimedia medical documents.

This paper describes the prototype of a coder/decoder based on the Open Document Architecture (ODA) standard for management of medical documents, as well as the working environment in which it has been developed. The prototype has been assessed in an X-Windows-equipped workstation with a relational database containing patient folders (text and still images) from the departmental information system of the liver transplantation unit.

Humans↗
PubMed1993

Care plan for documenting pharmacist activities.

At a 393-bed hospital, a pharmaceutical care plan was developed and tested in a surgical intensive care unit (SICU). The trial care plan was developed and implemented with the following objectives: to integrate clinical and distributive elements of patient information in a care plan; to add new monitoring and intervention parameters to the pharmacy profile; and to assess and refine the care plan for implementation in other areas of the institution. One pharmacist performed and documented care for 10 patients in the SICU. The pharmacist planned appropriate drug administration schedules, noted appropriate indications for each medication ordered, established appropriate outcomes, monitored for drug-drug or drug-food interactions and allergies, recorded interventions and averted adverse drug reactions, and recorded the amount of time required for care according to disease state. Pharmacist involvement with medication administration and monitoring seemed to prevent many adverse effects and drug interactions. Because of the diversity of the patient population, there was substantial variation in the time spent on care. A trial pharmaceutical care plan in a surgical intensive care unit was useful for documenting pharmacists' productivity and effectiveness.

Colorado↗
PubMed1993

Computer-aided documentation. Quality, productivity, coding, and enhanced reimbursement.

PURPOSE: Physicians currently use technology, where appropriate, to improve patient care, for example, MRI and three-dimensional radiotherapy dose planning. One area that has seen limited benefit from current technology is in documenting of medical information. DESIGN: Review of related literature and directed interviews. RESULTS: Technology is available to assist in documenting the initial patient encounter. Patient care, quality of practice, and reimbursement may be improved with careful implementation. CONCLUSION: It will be worthwhile for practices to examine how to implement this technology to obtain the potential benefits.

Medical Informatics↗
PubMed1993

Documentation of nursing care for patients who have been restrained.

The care of patients who require restraints in the emergency department presents a challenge, not only for the amount and quality of behavioral interventions but also for the level of monitoring and documentation required. Special forms created to facilitate serial documentation of nursing care for patients who require restraints are designed to meet the unique needs of each emergency care facility.

Emergency Nursing↗
PubMed1993

[Computer controlled brain death documentation in the intensive care unit].

An interactive, knowledge-based computer system for brain death documentation is presented. The specific exponents BRAINDEX R and G were realised by the software tool Personal Consultant Plus and the programming language Clipper, respectively. The strategies of conclusion were forward chaining for approximate evaluation of coma stages and backward chaining for analysing the brain death syndrome. BRAINDEX was developed for use with an IBM personal computer or compatible equipment. Systemic analyses were compared retrospectively with the data from clinical brain death protocols (n = 132) of 128 comatose patients (mean age 35.1 +/- 15.8 years) with a Glasgow Coma Score of 3. Identical classifications (system vs physician) were found in all patients without diagnosis of brain death (n = 35). Differences related to the findings of the physician were evaluated in lower numbers of the systemic positive diagnosis of brain death (82 vs 89) and higher numbers of impossibility of systemic evaluation (11 vs 2). These results were obtained by conclusions of the computer system drawn by restrictive systemic mechanisms to avoid false-negative diagnoses. The system therefore seems to be useful for documentation, consultation, and as a teaching instrument and data bank in brain death.

Adult↗
PubMed1993

Modifying a Polaroid camera for close-up documentation.

A standard plus-three-diopter trial lens held in front of the objective lens of an inexpensive Polaroid camera produces close-up photographs of acceptable quality. This simple technique can be used to inexpensively document indications for plastic surgery and provide medicolegal documentation. The 23-millimeter-diameter trial lens provided acceptable resolution, but reduced depth of field; it must be well-centered to avoid vignetting.

Forensic Medicine↗
PubMed1993

Successful second unrelated donor BMT in a child with juvenile chronic myeloid leukaemia: documentation of chimaerism using the polymerase chain reaction.

A 3-year old child with juvenile chronic myeloid leukaemia received a T cell-depleted BMT from a male unrelated donor. There was early graft failure associated with increasing splenomegaly and hypersplenism. Splenectomy was performed 53 days post-transplant and was followed by autologous marrow recovery with return of leukaemia. A second unrelated donor BMT was performed 9 months later using T cell-replete marrow from a similarly matched female donor. Grade 2 GVHD involving the skin and gut responded to treatment with steroids. Chimaerism was assessed using Y-specific polymerase chain reaction (PCR) and microsatellites. Samples taken at the time of splenectomy showed no donor marrow engraftment but there was significant engraftment in the spleen. Following the second transplant, donor-type haematopoiesis was documented using a panel of microsatellite probes. The patient remains well 6 months after transplant. Splenectomy should be considered prior to transplant in patients with significant splenomegaly and hypersplenism. Partial chimaerism in the spleen, but not bone marrow, post-BMT, has not previously been documented. PCR technology is a useful and highly sensitive way to assess chimaerism post-BMT and is informative in sex-matched cases, whilst the small amount of material required is advantageous in paediatric patients.

Bone Marrow Transplantation↗
PubMed1993

[Duties of the Central Office for Documentation and Evaluation of Alternative and Supplementary Methods for Animal Experimentation at the Institute for Veterinary Medicine of the Federal Health Office, Berlin].

A National Center for Documentation and Evaluation of Alternative Methods to Animal Experiments (ZEBET) was established at the Department of Veterinary Medicine of the German Federal Health Office (BGA) in 1989. It is supporting wherever possible the basic principles of animal protection: to replace animal experiments, to reduce the number of laboratory animals in experiments, and to reduce the suffering of those animals used in experiments. ZEBET is responsible for documentation of and information on alternative methods to animal experiments. ZEBET is also the national center for planning, funding and coordinating validation programs for alternative test methods and has laboratory facilities for developing new experimental approaches.

Animal Testing Alternatives↗