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At least 1,621 records · Page 90Linked to original sources
PubMed1998

Teaching portfolios: documenting teaching.

In recent years, teaching portfolios have been developed as a way teachers can document teaching scholarship and demonstrate their teaching accomplishments, skills, and strategies. Most medical schools reward good teaching, often with promotion on clinician-teacher tracks, thereby acknowledging the contributions made by clinical faculty who serve the academic mission as teachers. Teaching portfolios provide a means for teachers to demonstrate their teaching achievements and display their best work. This article gives recommendations for constructing a teaching portfolio and includes examples of what can be included.

Documentation↗
PubMed2005

From cure to palliation: staff communication, documentation, and transfer of patient.

In the transition from curative treatment to palliative care of a general end-of-life patient population, the internal communication of the acute care staff seems to be less than optimal. The communication had reference to the dialogue within the staff both before and after the decision to concentrate on palliative care, and possible transfer of the patient. This survey of Swedish nurses and physicians showed that most of 780 respondents wanted more internal communication, and a more individualized procedure of decision-making. All staff should be informed about the decision made but full agreement was not seen as realistic. The largest difference of opinion between nurses and physicians concerned the involvement of nurses in the decision-making about the transition. A uniform documentation of the decision to transfer care focus was the ideal. Approximately every fourth patient in acute care is transferred to receive palliative care. Only approximately half of the respondents had any training in palliative care and the majority wanted more training. There seems to be a need for more palliative care training, perhaps somewhat different for each specialty. Furthermore, a common language to enable nurses and physicians to communicate more easily may improve the transition process.

Communication↗
PubMed2001

Program to remove incorrect allergy documentation in pediatrics medical records.

The incidence of incorrectly reported drug allergies in a pediatrics hospital and the effectiveness of pharmacist interventions to clarify these reports were studied. A four-month prospective study included children (< or = 18 years of age) with at least one drug allergy reported in their medical chart. Drug allergies were assessed by a pharmacist who labeled the reactions as true, incorrectly reported, or undetermined allergies, in accordance with defined criteria. When an incorrectly reported allergy was removed from a patient's chart with the consent of the attending physician, the intervention was reported to the community pharmacist. A total of 186 of 248 drug allergies identified in 1591 patient charts were challenged. Of these, 26 (14%), 103 (55%), and 57 (31%) were considered true, undetermined, and incorrectly reported drug allergies, respectively, by the pharmacist. A total of 53 (93%) incorrectly reported allergies were removed from patients' charts with the consent of the attending physicians. Community pharmacists were contacted in 25 of these cases. At follow-up, the incorrect allergy documentation was found to have been removed from 23 community pharmacy charts. A pharmacist found numerous incorrectly reported allergies in a pediatrics hospital and assisted in removing them from patients' medical charts.

Adolescent↗
PubMed2000

Recognition and documentation of domestic violence in the clinical setting.

Critical care nurses may encounter a victim of domestic violence or abuse when caring for an individual with traumatic injuries. Understanding the injuries that are associated with acts of violence is only the first step. A vital part of the nurse's responsibilities is the precise written documentation of observations, physical assessments, and other factors that may later become vital evidence in a court of law.

Documentation↗
PubMedDate not supplied

Photographing the patient with burns for medical documentation.

Photographs of a burn injury provide an objective description of the patient's disease course and may be important in the medicolegal documentation of child abuse or other criminal and civil actions. Accurate and reproducible photographs require careful composition and choice of equipment. Standardized clinical positioning is described with recommendations for timing of serial photographs.

Burns↗
PubMed1981

Documenting outpatient problem intervention activities of pharmacists in an HMO.

The outpatient drug use review experiences by pharmacists at a large health maintenance organization with on-site pharmacies were investigated. Pharmacists were asked to document the nature of potential drug therapy problems encountered, drug involved, review activities undertaken, and process-outcomes. Patterns of pharmacists intervention were observed over 1 year. Results indicated that the number of problems detected increased substantially during the months immediately following the introduction of problem recording and feedback procedures. During the latter months, the number of prescriptions with problems approximated 4 per 100 dispensed prescriptions. Drug interactions of a moderate nature and drug underuse were the most frequent problem types encountered. Most were not serious and usually resulted in a cautionary or counseling message given to patients by pharmacists. The next most frequently occurring type was drug overuse problems, and, after that, problems concerning some aspect of the prescribing decision. In 9 per cent of all problem interventions and in 44 per cent of prescribing-problem interventions, the outcome of the pharmacist intervention was a change in drug, strength or directions for use. The average amount of pharmacist time per problem intervention varied from 6.0 to 7.8 minutes across problem types. This approximate a pharmacist labor cost of $0.06 per dispensed prescription, given a problem encounter rate of 4 per 100 dispensed prescriptions.

Documentation↗
PubMed2000

Long-term care demands precise documentation.

It's more common for the elderly to die in long-term care versus acute care. Their needs are also far more varied, as is the facility's liability exposure. Learn how caregivers' documentation can save lives and reduce liability.

Aged↗
PubMed1978

A new method of documenting hand cases.

A photocopier can be used as a helpful adjunct in the precise documentation of the condition of the hand. It is cheap and easy to use, and it provides a permanent and accurate record.

Copying Processes↗
PubMedDate not supplied

Reducing medical errors through better documentation.

Preventable medical errors occur with alarming frequency in US hospitals. Questions to address include what is a medical error, what errors occur most often, and what solutions can health information technologies offer with better documentation. Preventable injuries caused by mismanagement of treatment happen in all areas of care. Some result from human fallibility and some from system failures. Most errors stem from a combination of the two. Examples of combination errors include wrong-site surgeries, scrambled laboratory results, medication mishaps, misidentification of patients, and equipment failures. Unavailable patient information and illegible handwriting lead to diagnosing and ordering errors. Recent technology offers viable solutions to many of these medical errors. Computer-based medical records, integration with the pharmacy, decision support software, Computerized Physician Order Entry Systems, and bar coding all offer ways to avoid tragic treatment outcomes. Persuading and training hospital staff to use the technology poses a problem, as does budgeting for the new equipment. However, the technology would prove its worth in time. The Institute of Medicine and coalition groups such as Leapfrog Group have recognized the problem that permeates the health care industry, manifests in many ways, and requires the many solutions that information technology offer.

Decision Support Techniques↗
PubMedDate not supplied

A nursing portfolio: documenting your professional journey.

Professional profiling may enhance one's career development. The opportunities to use a current profile abound, and include applying for a new position, a leadership role in a professional society, a scholarship or an award, or career advancement. The true professional updates the profile on an annual basis, emphasizing significant personal and professional accomplishments. Documentation and validation of one's credentials may require substantial effort-but such effort is worth it. Profiling is a step toward recognition and success.

Career Mobility↗
PubMed2006

The emergency department triage of community-acquired pneumonia project data and documentation systems: a model for multicenter clinical trials.

Multicenter clinical trials are complex undertakings that require significant resources to ensure efficient, high quality research. This paper describes the goals, design, and implementation of a multicenter clinical trial database management system to support this aim. A large number of study sites or patients, and the goal of automatically generating large portions of data management infrastructure from common metadata, motivated the development of the system. This paper also describes extensions for a generalized project documentation system, and discusses plans for further extensions and improvements based on observed strengths, limitations, and anticipated technological change.

Community-Acquired Infections↗
PubMed2006

Metric learning for text documents.

Many algorithms in machine learning rely on being given a good distance metric over the input space. Rather than using a default metric such as the Euclidean metric, it is desirable to obtain a metric based on the provided data. We consider the problem of learning a Riemannian metric associated with a given differentiable manifold and a set of points. Our approach to the problem involves choosing a metric from a parametric family that is based on maximizing the inverse volume of a given data set of points. From a statistical perspective, it is related to maximum likelihood under a model that assigns probabilities inversely proportional to the Riemannian volume element. We discuss in detail learning a metric on the multinomial simplex where the metric candidates are pull-back metrics of the Fisher information under a Lie group of transformations. When applied to text document classification the resulting geodesic distance resemble, but outperform, the tfidf cosine similarity measure.

Algorithms↗
PubMed2005

Documenting end of life decisions in residential aged care facilities in South Australia.

OBJECTIVE: This research examined the provision of palliative care for residents with a non-cancer diagnosis including the use of advance directives and advance care planning as part of palliative care policies in residential aged care facilities in South Australia. There are no guidelines for recording residents' wishes if they are no longer competent. METHODS: Stage 1 involved a survey of 90 randomly selected aged care facilities. Stage 2 involved case studies of 69 residents, appropriate for palliative care, from 17 facilities and interviews with 15 directors of care. RESULTS: Most residential aged care facilities used forms to record residents' wishes about end of life care, but there was little consistency. Some had no palliative care policy and few facilities required a formal advance directive. Not all residents had formally appointed a proxy. CONCLUSIONS: Residential aged care facilities should be required to develop and implement a palliative care policy acknowledging the Accreditation Standards and State legislation and including a simple tool for advance care planning. Case conferencing could assist in discussing and documenting the resident's wishes. Public education is essential to increase community and professional awareness in order to promote empowerment for the increasing number of older people who will die in residential aged care facilities.

Advance Care Planning↗
PubMed1998

Perioperative documentation: are we doing enough?

We performed a retrospective analysis to assess the content and accuracy of operative and anaesthetic records for Caesarean section in a large unit. The obstetric record was considered adequate if it included patient identification, participating doctors, operative date, title, details and findings and a signature. The anaesthetic record was evaluated by The Australian and New Zealand College of Anaesthetists guidelines. We analysed 104 operative and 101 anaesthetic records. There was inadequate identification in 17 (16.3%) of the operative records. Documentation of a previous scar or the presence or absence of intraabdominal adhesions was incomplete in 22 of the 35 patients (63%) with a previous laparotomy. Sixty per cent of records had incomplete skin closure information. Common anaesthetic record deficiencies were patient position, patient airway, investigation results and postoperative plan. Our findings identified deficiencies that could lead to inadequate medical care and indicate the need for improved standards of perioperative records.

Anesthesia, Obstetrical↗