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 1,567 records · Page 87Linked to original sources
PubMed1998

Methylenetetrahydrofolate reductase C677T mutation, plasma homocysteine, and folate in subjects from northern Italy with or without angiographically documented severe coronary atherosclerotic disease: evidence for an important genetic-environmental interaction.

Moderate elevation of plasma total homocysteine (tHcy) is a strong and independent risk factor for coronary artery disease (CAD). It can result from genetic or nutrient-related disturbances in the transsulfuration or remethylation pathways for Hcy metabolism. A point mutation (C677T; Ala-to-Val) in the gene encoding the 5, 10-methylenetetrahydrofolate reductase (MTHFR) has been recently reported to render the enzyme thermolabile and less active. Studies on the role of this mutation as a risk factor for CAD have given conflicting results. We studied a total of 415 subjects, 278 with angiographically documented multivessel CAD and 137 with angiographically documented normal coronary arteries. The overall frequency of the MTHFR V/V homozygous genotype was 15.7% (with 52.5% heterozygous and 31.8% normal). Subgroup analysis showed no significant differences between CAD and CAD-free subjects. A genotype/phenotype correlation study showed a marked effect of folate on the association between MTHFR genotypes and tHcy. Among individuals with folate levels below the median (11.5 nmol/L), fasting tHcy was significantly increased not only in V/V homozygotes (by 59%) but also, at intermediate values, in A/V heterozygotes (by 21% on average). Conversely, the mutation resulted neutral with respect to tHcy levels in subjects with adequate folate levels. We conclude that, in our population, the MTHFR C677T mutation is rather common, but it does not appear to be associated per se to CAD. A genetic-environmental interaction may contribute to the vascular risk by elevating tHcy when folate status is low.

Adult↗
PubMed1976

[The implementation of a computerized documentation system for the evaluation of spa therapy in patients with rheumatoid arthritis (author's transl)].

A previously-described documentation system for articular examination was applied to evaluate the results of spa treatment in 20 patients with rheumatoid arthritis during 3 separate treatment periods. Physical joint findings were documented and indices were compiled by means of a computer before, during and after treatment with thermal water the first year, normal water the second year (or vice versa) and without baths at all in the third year. These indices were compared statistically. Each kind of treatment produced a statistically-significant improvement in the disease, there being no significant difference in the results achieved by the 3 therapeutic regimens.

Arthritis, Rheumatoid↗
PubMed1998

Interinstitutional comparison of bedside blood glucose monitoring program characteristics, accuracy performance, and quality control documentation: a College of American Pathologists Q-Probes study of bedside blood glucose monitoring performed in 226 small hospitals.

OBJECTIVES: To assess the accuracy of bedside blood glucose monitoring (BGM) in small hospitals, to assess the compliance with which hospital workers performing bedside BGM adhere to quality control (QC) procedures, and to identify those practice characteristics in small hospitals that are associated with better BGM accuracy and with better performance of BGM QC. DESIGN: Over a 1-month period in 1996, voluntary participants in the College of American Pathologists Q-Probes laboratory quality improvement program prospectively compared glucose results of 30 split samples run on BGM instruments with those performed on laboratory glucose analyzers, collected quality control data on up to five inpatient BGM instruments, and completed questionnaires profiling BGM practice characteristics in their institutions. SETTING AND PARTICIPANTS: Two hundred twenty-six hospitals with 200 or fewer occupied beds. MAIN OUTCOME MEASURES: The percentages of glucose determinations performed on BGM instruments differing by more than 10%, 15%, and 20% from those split-sample results performed on laboratory glucose analyzers; the percent of BGM QC determinations required by institutions' BGM QC programs that BGM operators actually performed; and the percent of patient values reported when BGM QC was documented to be out of range and uncorrected, or reported when BGM QC was not performed at all. RESULTS: Of 6095 split-specimen glucose results that participants simultaneously performed on BGM instruments and on laboratory glucose analyzers, 45.6% differed from each other by more than 10%, approximately 25% differed from each other by more than 15%, and almost 14% differed from each other by more than 20%. Of 216 laboratories that performed at least 30 QC events during the study period, slightly over a third completed 100% of their required QC determinations, and 10% completed, at most, 77% of their required BGM QC determinations. Of 115,973 BGM determinations that participants reported on hospitalized patients, 3.3% were reported when QC was either out of range or when there was no documentation that QC had been performed at all. Better accuracy and/or better QC performance was associated with laboratory personnel rather than nursing personnel both supervising institutions' BGM QC programs and running institutions' daily routine BGM QC; with BGM operators both routinely running three, rather than two, levels of QC analytes; with BGM operators regularly comparing BGM results with laboratory analyzer glucose results; and with institutions participating in external proficiency programs. Institutions that completed all required BGM QC tasks tended to perform better on the BGM accuracy study than did those institutions that completed, at most, 77% of their required QC. CONCLUSIONS: We found the rates of BGM accuracy and of QC performance adequacy achieved in small hospitals to be similar to those determined in previous Q-Probes studies conducted in large institutions. A significant amount of institutional bedside testing does not meet current standards for accuracy or for quality control. Some institutions may improve their accuracy and/or QC performances by having laboratory personnel intimately involved in their institution's BGM QC program, by routinely comparing BGM results with those performed using glucose analyzers in the clinical laboratory, by routinely running three rather than two glucose QC control levels, by participating in external proficiency programs, and by strictly adhering to institutional QC protocols.

Australia↗
PubMed1998

[Documented effects of SSRI preparations in anxiety].

The article consists in a review of the clinical evidence for treating anxiety disorders with selective serotonin re-uptake inhibitors (SSRIs). Sufficient documentation now exists to support the use of SSRIs in treating panic and obsessive-compulsive disorders, and in Sweden moclobemide is now approved for use in treating social phobia, and buspirone for use in treating generalised anxiety disorder. Further documentation of the treatment of post-traumatic stress disorder with SSRIs is probably to be expected. Benzodiazepines remain the most commonly used anxiolytics. Although persistent adverse sexual reactions, and withdrawal symptoms upon abrupt termination of medication, are notable side effects of SSRIs, patients become measurably more self-confident and focused, and manage risks more adequately. This underscores the need of further research into the interrelationship of personality traits and anxiety symptoms.

Anti-Anxiety Agents↗
PubMed1998

[Ethics and rights in biomedical research: documents by the Council of Europe and UNESCO].

After having indicated, in brief, the international documents of major interest for the safeguard of the human being subject to biomedical experiment, the author dwells upon two recent initiatives: "Convention for the safeguard of the human rights and the dignity of the human being with regard to the applications of biology and medicine: agreement on humans rights and biomedicine" by the Council of Europe and "Draft of declaration on human genome" issued by UNESCO. Of both documents he explains the genesis and the main objectives that are aimed to be reached. In particular, he dwells upon the contents of those articles that concern scientific research. Finally, he positively evaluates the promotional effort of the human being rights that the two initiatives pursue, highlighting however that there are some limits under a strictly bioethical profile.

Ethics Committees↗
PubMed1998

HOLON: extending Web document libraries via objects in order to support the health information infrastructure. Health Object Library Online.

In HOLON, user clients, applications, data servers, and fine-grained elements are all objects in a document library. To that end, this paper reviews the past year of progress and lessons learned in HOLON for integrating the Web, HL7, CORBA, Arden, KQML, UMLS Thesaurus, and other standards to determine if object technology reduces common problems in document-centric libraries such as indexing, searching/retrieving, complex data type management, and maintenance, among others.

Computer Systems↗
PubMed2005

Computer-based documentation: effect on parent and physician satisfaction during a pediatric health maintenance encounter.

OBJECTIVE: To investigate the impact of a computer-based documentation (CBD) tool on parent and physician satisfaction with a pediatric health maintenance encounter. DESIGN: The project used a preintervention and postintervention design. The preintervention group visits used paper-based forms for data entry, whereas the postintervention visits used CBD. At the conclusion of each encounter, both the physician and the parent completed a survey that assessed their perceptions of the encounter's quality. SETTING: Urban hospital-based pediatric teaching clinic. PARTICIPANTS: Parents and physicians of children 18 months and younger. MAIN OUTCOME MEASURES: Parent and physician satisfaction with 7 components of a health maintenance encounter (interim history, social history, anticipatory guidance, developmental assessment, physical examination, assessment, and plan). RESULTS: There was no change in overall parent or physician satisfaction in the areas of communication or physician helpfulness. Physicians using CBD were less likely to agree that they provided clear explanations but were also less likely to agree that they "acted bossy during the visit." There was no correlation between physician and parent satisfaction or between physician satisfaction and pattern of CBD use. However, there was a strong correlation between physicians' satisfaction and the extent to which they found CBD helpful (Spearman rho = 0.29, P<.001). CONCLUSIONS: The introduction of CBD into the health maintenance encounter did not affect measured aspects of parent or physician satisfaction; these results support its continued use in that setting.

Attitude to Computers↗
PubMed1997

Patient datasheets and generic evaluation sheets: tools for improving patient care, patient satisfaction, and chart documentation while decreasing physician frustrations.

A medical record system that utilizes a patient datasheet and pretyped generic patient evaluation sheets is described. When completed, the patient datasheet facilitates quick access to all of the pertinent patient medical information, improves transmission of instructions to the patient, simplifies record-keeping of patient visits, prevents the rewriting of repetitive information (such as a long list of medications and dosages and instructions after each visit), facilitates the tracing of the patient medication history, and improves communication with the patient and with other physicians. The "generic evaluation sheets" have a near-complete medical history and physical examination already typed with areas where information can be easily added or deleted and provides a place for the patient assessment and medical treatment plan. This approach to outpatient medical record-keeping not only results in the ready availability of patient medical information, thus decreasing some of the frustrations of patient care, but also markedly improves patient care documentation while facilitating referral letters and in-hospital patient records.

Communication↗
PubMed1993

The qualitative research audit trail: a complex collection of documentation.

A qualitative study typically involves a large volume of researcher-generated data, including notes about the context of the study, methodological decisions, data analysis procedures, and self-awareness of the researcher. Such data are important in many aspects of the study, particularly in the development of an audit trail to substantiate trustworthiness. Unfortunately, there is little information available to assist researchers in generating the needed documentation. In this article, we discuss the types of data that contribute to credible investigations. Strategies for maintaining effective records in qualitative studies are included, along with examples from our own research.

Data Collection↗
PubMed1976

[Computer-oriented documentation of quantitative and qualitative data in gastroenterology (author's transl)].

Computer-oriented documentation of quantitative and qualitative data obtained from patients with gastroenterological diseases is described as an example of a method when considering a relatively small number of patients. All qualitative and quantitative features are entered uncoded in a data booklet and subsequently on port-a-punch cards. After extensive computerized error check - and correction, as need arises, - the data are transferred to a data base and stored on magnetic disk. The ISIS information system, in conjunction with special routines provides access to the data in any combination desired. Analysis of the data, both on an individual and a statistical basis is thus facilitated.

Diagnosis, Computer-Assisted↗
PubMed1978

[D. Documentation and statistics. Therapy code for all surgically active disciplines].

The study group of the German Society for Medical Documentation. Information and Statistics presents a suggested code that is an extension of VESKA. Since it only extends from Head to Gynecology, the Eltze-Eichler code is recommended for Orthopedics and Extremities. A general 6-digit code classified under different facets is being developed.

Documentation↗
PubMed1995

Recovered memories of abuse in women with documented child sexual victimization histories.

This study provides evidence that some adults who claim to have recovered memories of sexual abuse recall actual events that occurred in childhood. One hundred twenty-nine women with documented histories of sexual victimization in childhood were interviewed and asked about abuse history. Seventeen years following the initial report of the abuse, 80 of the women recalled the victimization. One in 10 women (16% of those who recalled the abuse) reported that at some time in the past they had forgotten about the abuse. Those with a prior period of forgetting--the women with "recovered memories"--were younger at the time of abuse and were less likely to have received support from their mothers than the women who reported that they had always remembered their victimization. The women who had recovered memories and those who had always remembered had the same number of discrepancies when their accounts of the abuse were compared to the reports from the early 1970s.

Adolescent↗
PubMed1989

[Simple and clinically useful documentation on the vulva using a personal computer].

We developed a simple menu driven database on personal computer for classification and documentation of vulvar lesions (IBM-PC, dBaseII). Vulvar lesions were classified according to morphologic appearance: red, white, dark, ulcer, small tumor (less than 1 cm), large tumor. The data for each category are entered in multiple choice form and stored in a separate database file. For each category an automated table of the frequencies of the different diagnoses is provided, individual patients and variables can easily be accessed through the database query language.

Documentation↗
PubMed1992

[PC-assisted planning and documentation of the surgical schedule].

A computer program for personal computers was developed to support and control the schedule in the operation theatre. With this program a great amount of operational and medical data will be recorded (e.g. the duration of operation and anesthesia, the number of operating rooms occupied, the personnel involved, the diagnosis and surgical therapy). The screen shows up-to-date information about the ongoing events. All data can be easily evaluated for different criteria. In a four years period the program presented has proved valuable for daily routine planning and documentation in a great operation unit.

Database Management Systems↗
PubMed1999

[The incidence of perioperative events with optimized documentation discipline].

AIM: The German Society of Anesthesiology and Intensive Care Medicine evaluated the standardized reporting of perioperative anaesthesia-related incidents, events, and complications (IEC). As part of the data validation efforts, the problem of variation in documentation procedure was evaluated. METHODS: A study group of particularly motivated and instructed residents and attendants was scrutinized at a University teaching hospital from April through June 96. IEC assessment was completed according to the Society's definitions. RESULTS: Out of 4242 anaesthetics during the study period 839 (19.8%) were completed by the study group. In the univariate analysis, the incidence of IECs was significantly (P < 0.001) more reported by the physicians studied (36.4%) than by the control group (18.6%). In a multivariate analysis, while adjusting for all covariables, reported incidence of IEC was 2.4-fold significantly increased (P < 0.001). CONCLUSIONS: This study is another step in validating the assessment of IECs. The results gain importance with respect to upcoming nationwide quality comparisons among anaesthesia providers. In addition, they give a better estimate of economic implications from IECs within the institution.

Analysis of Variance↗
PubMed2003

[Interdisciplinary cooperation as a prerequisite for precise tumor documentation. Illustrated by an example of surgery for colorectal carcinoma].

Current tumor management is increasingly founded on interdisciplinary cooperation. The main partners in cases of solid tumors are oncologic surgery, medical oncology,and radiotherapy, guided by pathology. The cooperative concept, particularly the individual strategy and selection of the most adequate approach, oriented on guidelines and therapeutic standards, depends on the quality of the involved components as well as personal abilities of the "actors." In addition to the personal qualification, decision making depends on both tumor stage and completeness of tumor removal. In this point, the overall quality of the therapeutic concept is based on an interaction between the operating surgeon and clinical pathologist that had seldom been taken into consideration. The basic rules of their cooperation and quality-focused implementation regarding tumor dignity, stage, and R classification are discussed based on the example of colorectal carcinoma. In particular, those pitfalls in tumor documentation are emphasized,which may appear less relevant for each partner individually, but bear the risk of misinterpretation and therefore misleading conclusions.

Colon↗
PubMed1996

[Patient specific documentation of complications in trauma surgery. Concept, problems and results].

Quality management requires correct and comprehensive monitoring of all complications. Since January 1995 in the department of trauma and orthopaedic surgery complications have been recorded immediately when the patient is scheduled for reoperation or when complications become evident during the X-ray conference or at follow-up clinics. Two senior surgeons note all available information on a sheet of paper. Data are completed as soon as possible and entered into a PC data base. All cases are followed up by the respective surgeon and discussed at monthly complication conferences. A case is not closed until the end result has been documented. We discuss the theoretical and practical problems of this procedure and present the statistical evaluation for 1995.

Documentation↗
PubMed1994

[Microfilm documentation in follow-up of melanocytic tumors].

Microfilm photography allows documentation of naevi in a map-like fashion. The localization of multiple naevi is no longer a problem, as one can scan the film. Comparison of the magnified film with the patient can be done in day-light. Magnification up to 48 times is possible. Detection of early changes of the naevi, during the horizontal growth phase, should increase the 5-year survival rate.

Cell Transformation, Neoplastic↗