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 1,549 records · Page 86Linked to original sources
PubMed1993

Outcome of a quality assurance review: development of a documentation tool for chemotherapy administration.

Nursing quality assurance (QA) is a systematic evaluation program to promote quality nursing practice. As part of a QA project, hospital records of 28 patients who received chemotherapy were reviewed to determine whether nursing documentation of chemotherapy administration complied with the standards of oncology nursing practice. Because the audit identified some deficiencies in documentation, a flow sheet was developed to resolve problem areas. A retrospective audit of 18 charts was conducted six months after the new flow sheet was initiated. The audit revealed 100% compliance for each key indicator that was evaluated. This article describes the QA process that led to the development and evaluation of the new flow sheet.

Antineoplastic Agents↗
PubMedDate not supplied

Capturing scarce resources: documentation and communication.

When charting does not reflect nursing activities, reimbursement may be denied. Skilled nursing care documentation of quality care rendered allows for reimbursement. Accountability for nursing care goes beyond planning and implementation; it also includes responsible recording and communication of activities. There are many chronic conditions that benefit from nursing intervention yet are not part of admitting diagnoses. Urinary incontinence is an example of a common problem encountered by nurses in hospital settings that requires time, patience, knowledge, and skill to assist those having this condition. It is cost effective to provide the care necessary to improve the treatment and management of urinary incontinence; it is revenue effective to assure that nursing and medical documentation is complete to cover the cost of nursing time and expertise spent providing care to patients with this condition.

Communication↗
PubMed1995

Digital optical card. A promising technology for documentation and communication of images.

PURPOSE: To assess a patient-oriented digital optical card (OC) for documentation and communication of images using the analysis of breast microcalcifications to illustrate its resolution power. METHODS: Fifty film mammograms with histologically proved clustered microcalcifications were digitized using a 5 lp/mm CCD-scanner. A region of interest containing the cluster was selected for documentation on an OC as an overview OC-image and as a magnified OC-image (5 lp/mm). The shape (spherical/nonspherical) as well as the total number of microcalcifications were quantitatively analyzed by 2 radiologists. RESULTS: The detection rate for total number of overall and spherical microcalcifications using digital media was significantly reduced (p < 0.01) compared to analog mammography. There were no significant differences in the detection rate of nonspherical microcalcifications between film mammograms (100%) and magnified section OC-images (92.7%). The overview OC-image revealed 72% of those calcifications (p < 0.01). CONCLUSION: According to our results, this technology is not appropriate for diagnosis of breast microcalcifications, but may be a promising communication digital medium for transmitting an image/report unit to referring physicians.

Breast Neoplasms↗
PubMed1995

A document processing architecture for electronic medical records.

An Electronic Medical Record System (EMRS) requires a deep analysis of the clinical workplace and of the character and uses of the medical record itself. Charts are a diverse and useful collection of loosely structured specialized documents, each with an orderly outline, but widely divergent and unpredictable contents--the more critical the case, the more unpredictable the details. This can be achieved by adapting an underlying information architecture that is based on document processing (rather than data processing), using the logic and conventions of text tagging, as in Mosaic, the Standard Generalized Markup Language (SGML), and HyTime.

Medical Records↗
PubMed1995

Education strategy for the implementation of computerized nursing documentation.

Educators at The Toronto Hospital took an innovative approach to providing education and support to nursing staff prior to, during, and after the implementation of computerized nursing documentation. The education strategy included a combination of formal classroom training, inservices on the unit, a self-learning package and an electronic scavenger hunt. Resources such as Clinical Teachers, Clinical Nurse Specialists and Information Systems Analysts and Educators who provided support during the implementation phase received additional education to prepare for their role on the nursing units. Nurses were provided intensive twenty-four hour support for a period of four weeks, and a documentation checklist helped monitor the progress of individual nurses during the implementation. This strategy was designed to maximize consistent support and to minimize cost.

Attitude to Computers↗
PubMed1995

4.5 years of experience with an electronic patient record system at the University of Munich: PADS (Patient Archiving & Documentation System).

We demonstrate an Ethernet based local area network (LAN) with clinical workstations (Apple Macintosh). The patient archiving and documentation system (PADS) represents a computerized patient record system presently used in a university hospital's ICU, CCU, and oncology unit [1]. Since 1990, over 100 users have documented more than 6,000 patient admissions, equaling 30% of all inpatient admission in our hospital. Taking full advantage of the macintosh based graphical user interface (GUI), our system enables nurses and doctors to perform the following tasks: admission, medical history taking, physical examination, generation of problem lists and follow up notes, access to laboratory data and reports, and the semiautomatic generation of a discharge summary including full word processor capabilities. Furthermore, the system offers rapid, consistent, and complete automatic encoding of diagnoses following the International Classification of Disease (ICD - 9 CM; WHO). The system has links to other educational programs such as cardiac auscultation and image analysis. A MEDLINE literature search through a CD-ROM based system can be performed from within the system. CD-ROM based medical textbooks can be accessed as well. Users can customize their working environment and use any commercially available macintosh programs from within the main application. Additional options include: automatic background monitoring of users learning behavior, analyses and graphical display of numerous epidemiological, and healthcare related problems. Furthermore, sound and digital video can be recorded in our system. E had initially developed a relational database 4GL development tool in the rapid prototyping phase, and have since completed the next step of development: rewriting the complete application using C++ and Oracle. The user interface has hardly changed, maintaining the "look & feel" of the initial application and introducing the performance of a professional relational database management system (RDBMS). This system represents one in a line of modular departmental models which are being integrated to form a decentralized hospital information system (HIS) at the University of Munich. The proposed theater-style demonstration will walk the audience through the system simulating a true patient admission and work up.

Germany↗
PubMed1996

Interdisciplinary documentation in the NICU.

A continuous quality improvement (CQI) project focused on documentation within the Newborn Intensive Care Unit (NICU) at Primary Children's Medical Center. The task force developed and implemented an interdisciplinary patient care documentation system that reduces duplication, increases compliance, improves communication and is fiscally responsible.

Forms and Records Control↗
PubMedDate not supplied

Bar code documentation of pharmacotherapy services in intensive care units.

Bar code technology has been used for 5 years to improve the efficiency of identifying and documenting clinical pharmacy services at our institution. Data for an entire year (1993) were analyzed to quantify the nature and magnitude of pharmacy services provided for critically ill patients in intensive care units (ICU). Patients in the medical (MICU), respiratory (RICU), intermediate (IMU), and surgical (SICU) units (3234/3743 patients, 86%) were reviewed. Clinical interventions and expected outcomes were documented by pharmacists using an automated bar code system. There were 11,628 pharmacotherapy interventions, 3.6/patient; 12/pharmacist work day. Of patients whose drug therapy was reviewed at least once, 50% (1610/3234) received at least one intervention. The mean number of interventions/patient was 7.2 in the MICU, 6.1 in RICU, 3.4 in IMU, and 2.4 in the SICU, corresponding to APACHE III scores of 71.2, 66.2, 42.8, and 43.3, respectively. The majority of interventions were to modify dosages of antimicrobial agents, and were performed to achieve optimum efficacy (42%) and to minimize toxicity (46.2%). These data support the necessity for pharmacists to provide individualized care to critically ill patients.

Drug Therapy, Computer-Assisted↗
PubMedDate not supplied

Documenting for patient-focused care.

Hospitals across the country are rethinking the way health care is delivered. With a shift from inpatient to outpatient care, there is an effort to deliver quality, "patient-focused care" in the hospital setting. Multidisciplines have embarked in cross-training to provide immediate services at the bedside. The premise of "nursing" documentation is no longer feasible in multicaregiver environments. One hospital's adaptation to documentation methods to meet the needs of a patient-focused system is described.

Forms and Records Control↗
PubMed1996

Radiology CME on the Web using secure document transfer and internationally distributed image servers.

We describe the implementation of a World Wide Web-based Continuing Medical Educational (CME) program in Diagnostic Radiology which allows accumulation of Category I credit. The program implements an unknown case presentation format which includes multiple choice questions, didactic information, and literature references with links to abstracts. Physician participation is anticipated to occur in brief sessions during which the program automatically tracks CME credit accumulation. To allow an interactive presentation, HTML electronic form documents are created "on the fly" by a Common Gateway Interface (CGI) application interfacing with several relational databases. The system is scalable with bandwidth intensive image transfers distributed over multiple internationally distributed image servers. For CME participants, the system utilizes documents encryption to ensure confidential physician interactions.

Computer Communication Networks↗
PubMedDate not supplied

Clinical protocols herald new era of nursing documentation.

Documenting care tends to be a time-consuming process and information is often replicated. This paper describes how documentation was changed in one acute hospital trust to reflect UKCC guidelines and for use by all disciplines. Evaluation suggests that less time is spent writing records and that those records are more complete.

Aged↗
PubMed1997

Dental health status associated with documented dental attendance patterns in adolescents.

OBJECTIVE: To investigate the dental health of adolescents who exhibited four different patterns of documented dental attendance in regard to caries experience and types of treatment they received. DESIGN: The adolescents were categorised according to whether they had been asymptomatic or symptomatic attenders in childhood and whether this had changed in early adolescence. Asymptomatic attenders were those who attended for examinations at least twice in any three year period. Symptomatic attenders were those who attended for examinations less frequently than this. SUBJECTS: Treatment notes of 254, 13-15-year-old subjects who reported they were patients at one of 12 general dental practices or two community clinics were used to document attendance during the previous six years. RESULTS: Those who attended asymptomatically throughout the study period of six years had fewer teeth extracted and more sealed teeth than those who attended symptomatically. CONCLUSIONS: Among adolescents dental attendance in the absence of symptoms is associated with fewer missing teeth and wider provision of fissure sealants.

Adolescent↗
PubMed1997

Computer aided adjustment of the phrenic pacemaker: automatic functions, documentation, and quality control.

Electrical stimulation of the phrenic nerves of patients with complete ventilatory insufficiency with the Vienna respiratory pacemaker has been in clinical use since 1983. During the adjustment of stimulation parameters with this device, the following problems have occurred: for some measurements like the recruitment curve, series of complete inspiration cycles have to be stimulated, which causes the danger of muscle fatigue for unconditioned patients. The documentation is completed predominantly by hand, taking time and increasing the possibility of error. As a first step to solve these problems, we developed a new stimulation and measurement system. It consists of a PC with data acquisition hardware, the necessary sensors, and amplifier circuitry. The implanted stimulator is controlled via the parallel interface. The new system offers some advantages: computer control shortens the time for measurement and documentation, and the stress on the patient and the risk of error is reduced; synchronized measurement makes it possible to use single stimulation pulses instead of bursts and ramps to reduce diaphragm fatigue; digital signal processing improves measurement results and reproducibility; and help functions and self tests are provided, together with a graphical user interface. We used sensors for air flow, diaphragm EMG, and acceleration, on up to 8 channels simultaneously. Combined sample rates of up to 100 kS/s were possible. The system could be adapted for other uses involving functional electrical stimulation with our implantable nerve stimulators. Using this equipment saves a lot of effort, and the adjustment process can be focused on improved stimulation results and better performance for the patient. Current research is studying implementation of automatic functions like acquisition of stimulation thresholds. This could result in a predominantly automated adjustment of the phrenic pacemaker and even in a closed-loop controlled system in the future.

Computer Simulation↗
PubMed1997

[Neytumorin as biomodular onco-therapy--allegations without documentation].

NeyTumorin is a combination of peptides and proteins of 15 different organs from fetal and young pigs and cows. The list of indications ranges from cancer prevention to long-term treatment of malignancies. One vial of NeyTumorin-Sol costs DM 122.34. The therapy for a patient with a T1-2N0M0 cancer costs about DM 16,500 and an advanced stage up to over DM 100,000. The inventor of the Cytoplasmatic Therapy is K.E. Theurer. About 40 years ago, he founded the Vitorgan-Pharmaceutical Company which produces and distributes NeyTumorin. It is claimed that "physiological repair aids" from the cytoplasm of healthy animal organs induce a "hygiogenization" of the disturbed metabolism and NeyTumorin has immunogenic and immuno-modulatory effects which are important for the efficacy. The promotors classify NeyTumorin as a biological response modifier. The components of NeyTumorin are not defined. Preclinical investigations showing direct cytostatic and immunomodulatory effects are not sufficiently documented. Often extremely high concentrations of NeyTumorin were used. Clinical studies including prospective randomized trials are not conclusive because of false or insufficient documentation. There is no proof for either the claimed mechanism of action nor for a clinical efficacy.

Antineoplastic Agents↗
PubMed1997

Revising nursing documentation to meet patient outcomes.

Often, complex documentation forms place unnecessary burdens on nurses. A change in one hospital's patient care forms contributes to positive outcomes. With the revised documentation, nurses spend more time caring for patients while still meeting the Joint Commission on Accreditation of Healthcare Organizations' requirements.

Forms and Records Control↗
PubMed1997

[Digitalization, archival storage and use of image documentation in the GastroBase-II system].

"GastroBase-II" is a module of the clinical information system "KIS-ComSyD"; The main part is represented by structured data-text with an expert system including on-line image digitalization in gastroenterology (incl. endoscopic, X-ray and endosonography pictures). The hardware and software of the GastroBase are described as well as six-years experiences with application of digitalized image data. An integration of a picture into text, reports, slides for a lecture or an electronic atlas is documented with examples. Briefly are reported out experiences with graphic editors (PhotoStyler), text editor (WordPerfect) and slide preparation for lecturing with the presentation software PowerPoint. The multimedia applications on the CD-ROM illustrate a modern trend using digitalized image documentation for pregradual and postgradual education.

Expert Systems↗
PubMed1976

Management criteria, documentation, and peer review of initial urinary tract infection.

During part of a national study to formulate criteria for chart audit of quality assurance of child health care, criteria were developed for diagnosis and management of urinary tract infections. These criteria were validated by pediatricians and family physicians in academic medicine and in practice. They were judged relevant to the medical care process and patient outcome by both. The selected criteria were also recommended by the majority of two large physician groups for use in peer review. An important aspect of the study assessed the frequency of performing and recording indicated procedures or tests. In the first three phases of the study these criteria were said to be performed and recorded by a large majority of physicians. However, in the fourth (community) phase, when charts of 166 primary care physicians were actually audited, documentation was so poor that peer review by chart audit would be impractical at present. Assuming proper documentation of the medical care process, similar criteria could be used for chart audit, clinical research, and educational purposes. Since the diagnostic and management process of initial urinary tract infection is established, development of structured health care forms and education in proper record-keeping are two important challenges for those interested in the evaluation of ambulatory care.

Adolescent↗
PubMed1998

Did Milwaukee experience waterborne cryptosporidiosis before the large documented outbreak in 1993?

The patterns of incidence and pathways of spread for cryptosporidiosis are poorly understood. In this study, we explored the possibility that drinking water caused significant waterborne cryptosporidiosis in Milwaukee well before the massive documented outbreak in April 1993. We generated time series of daily counts of emergency room visits and hospital admissions for gastroenteritis in Milwaukee using the billing records of the Medical College of Wisconsin for January 1, 1992, through May 3, 1993. The Milwaukee Water Works provided us with data on drinking water turbidity for the same period. The service area of the South Plant experienced a sharp rise in turbidity just before the outbreak. During the outbreak period, gastroenteritis events were most strongly associated with turbidity at a lag of 7 days in children and 8 days in adults. It is reasonable to conclude that these lag times reflect the incubation period of Cryptosporidium. During the 434 days before the outbreak, gastroenteritis events were most strongly associated with turbidity at a lag of 8 days among children and 9 days among adults in the service area of the North Plant, the plant that experienced the highest effluent turbidity during this period. These findings are consistent with the conclusion that waterborne cryptosporidiosis was occurring in Milwaukee for more than a year before the documented outbreak.

Adult↗