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At least 1,639 records · Page 91Linked to original sources
PubMed1990

Anatomic rubber stamps of the face and body to document procedures in dermatologic surgery: one picture is worth a thousand words.

Representations of the anatomic surface location of cutaneous lesions and the surgical procedures performed on these lesions can be transferred to the medical charts using simple anatomic rubber stamps (ARS) of the body. The technique is exemplified with symbols to represent surgical excision, chemical face peel, dermabrasion, micrographic surgery, and the harvesting of flaps and grafts. ARS are also useful in liposuction surgery, punch grafts for pitted facial scars, hair transplantation, sclerotherapy, laser surgery, and other cosmetic dermatologic procedures. ARS are particularly valuable in micrographic surgery for skin cancer because they help document the depth and breadth of cancer invasion and aid in the follow-up of recurrent skin cancer, especially when defects are reconstructed.

Basal Cell Carcinoma↗
PubMed1988

Documented symptomatic bradycardia and symptom relief in patients receiving permanent pacemakers: an evaluation of the joint ACC/AHA pacing guidelines.

Recently, emphasis has been placed on documenting symptomatic bradycardia (DSB) before pacemaker placement can be justified in some patients. This study was designed to judge whether DSB improved the likelihood of symptom relief after pacing in 93 patients who had symptoms prior to pacing. Patients with complete heart block (Group A) had excellent symptomatic relief with or without pre-pacemaker DSB (100% vs 94%, P = NS). Patients with other diagnoses (Group B) also had a high incidence of symptomatic relief after pacing, regardless of whether or not DSB was present pre-implant (28/30 (93%) vs 23/28 (82%) P = NS). When evaluated as a test to predict the response to pacing for Group B patients, spontaneously occurring symptomatic bradycardia was neither highly sensitive (55%) nor highly specific (71%). Moreover, while the ability of a positive test to predict resolution of symptoms after pacing was high (93%), the ability of a negative test to predict a poor outcome after pacing was low (18%). The absence of DSB should not rule out permanent pacing for symptomatic patients in any diagnostic group. Future pacing guidelines should be revised to offer additional detail regarding the influence of symptoms, extent of asymptomatic bradycardia, and results of provocative tests in determining which implants should be classified as definitely indicated.

Bradycardia↗
PubMedDate not supplied

Organizing and documenting lactation support of NICU families.

A documentation tool designed for use by lactation consultants in the neonatal intensive-care unit provides an efficient and complete method for recording the progress of the mother and infant. It incorporates the research base into interventions that begin during the early postpartum period and continue through the preterm infant's hospital stay. The system for using this tool helps consultants in giving comprehensive and timely lactation support.

Breast Feeding↗
PubMedDate not supplied

Methodology-dependent variation in documentation of outcome predictors in out-of-hospital cardiac arrest.

OBJECTIVE: To identify variation in outcome predictor documentation in out-of-hospital cardiac arrest associated with two different methods of data collection: concurrent questioning of personnel following a resuscitation attempt and archival report review. METHODS: All patients > or = 18 years old who had out-of-hospital cardiac arrests, verified using the New York City 911 telephone system, between October 1, 1990, and April 1, 1991, were eligible for inclusion. The authors reviewed the first 200 cases of presumed primary cardiac arrest involving a resuscitation attempt among 3,243 consecutive ambulance call reports for cardiac arrest occurring during the study period. This archival data set was compared with data for the same 200 cases gathered through direct interview of field personnel by trained paramedics. The two data sets had been compiled independently by different individuals, using the same data collection instrument, which conformed to the Utstein template. RESULTS: Comparison of the data obtained from ambulance records with the data obtained from interviews of prehospital personnel revealed several areas of variance. Of note was a significantly lower proportion of bystander-witnessed ventricular fibrillation (VF) in the data set gathered from written reports (7% vs 18%; 95% CI for the difference 4-18%; p = 0.001). CONCLUSION: differences in methods of collection of out-of-hospital cardiac arrest data are associated with a more than twofold variation in the reported incidences of witnessed cardiac arrests manifesting as VF. Methodology-dependent variation in this important "denominator" may produce substantially different estimates of survival within the same cohort of patients.

Adult↗
PubMedDate not supplied

Effective systems documentation: essential for safety management.

The rapid pace of change in healthcare has caused critical engineering systems in hospitals and other healthcare facilities systems to be altered and upgraded on a virtually continuous basis. Changes to these systems, which include heating, ventilating, and air conditioning (HVAC), medical gases, normal and emergency electrical systems, plumbing, and fire protection systems, often are not properly documented. As a result, healthcare facilities may, over time, be exposed to increased risk. Such a situation compromises an organization's high level of patient and staff safety; it also may cause problems during a Joint Commission on Accreditation of Healthcare Organizations review of environment of care. This article outlines seven specific questions safety officers should review to determine if their facility needs a thorough systems assessment.

Documentation↗
PubMed2006

When is a door not a door? The difference between documented and actual arrival times in the emergency department.

OBJECTIVES: An observational study to determine the difference between documented ambulance arrival times and the actual arrival times of patients from the ambulance into the emergency department. METHODS: In a busy, purpose built, modern emergency department with easy access, we recorded the time that ambulance borne patients were wheeled over the threshold of the clinical area and compared this to the times recorded by the ambulance trusts as the official ambulance arrival times. RESULTS: 352 ambulance arrivals were observed. Data were incomplete in 34 instances (9.5%) and were not included in the analysis. For the remaining 318 arrivals, the median time difference was 2 min 1 s (range 5 s to 21 min 45 s). In a subgroup of chest pain patients (45 patients), the median time difference was 2 min 11 s (range 23 s to 5 min 38 s). The difference between the chest pain group and the remaining patients was not significant (p = 0.528). CONCLUSIONS: There is inevitably some delay between the arrival of an ambulance and the arrival of the patient into a clinical area. This study quantifies that difference. In an era of stringent time related standards, this paper highlights the need for accurate recording of times to enable us to carry out valid audit of these standards. This study supports the redefining of an arrival time as the time when the patient arrives in the clinical area.

Ambulances↗
PubMed1997

International documentation system for pancreatic cancer (IDS). The future in pancreatic cancer evaluation.

Different classification systems for pancreatic cancer have evolved in western countries as compared to Japan. While the UICC classification which is focused on tumour size and distant metastasis has achieved widespread acceptance, the more complicated Japanese system seems to be superior in the estimation of local growth. The major drawback of the JPS system, however, is the complex structure and difficult handling. To overcome both the international barriers in classification systems and to achieve a universal prospective data acquisition, a uniform international Documentation System for Exocrine Pancreatic Cancer (IDS for EPC) has been developed by an international group of pancreatologists. The present form of IDS is supported by a software program (based on Microsoft Access) which allows simplified data acquisition and statistical analysis as well as automated stage grouping for the UICC and JPS classifications. From the first contact with the patient, through all diagnostic and therapeutic measures including follow-up, IDS enables a compact and easy-to-use tool for prospective data acquisition and exchange on an international basis.

Documentation↗
PubMed2002

Role of a medical staff coding committee in documentation, coding, and billing compliance.

Physician documentation, Current Procedural Terminology (CPT) coding, and compliance with federal billing regulations are essential given the government's significant efforts to address fraud and abuse and the grave financial and legal consequences of noncompliance. Because Medicare guidelines do not focus substantially on psychiatric care, compliance is especially challenging for psychiatrists and psychiatric centers. Four years ago, the University of Texas-Harris County Psychiatric Center formed a medical staff coding committee to assist the center and its psychiatrists in dealing with compliance issues. The committee has evolved into a highly effective and important component of the institution's overall compliance program. The authors discuss the origins, development, and accomplishments of the medical staff coding committee.

Documentation↗
PubMed1997

Documentation of second-by-second breastfeeding behaviors using a novel method.

The specific way nursing patterns influence the duration of postpartum amenorrhea is unknown. This may result from the shortcomings of available methods: the daily log and recall. We tested these against a novel method, an event monitor (EM), consisting of a wrist-worn stopwatch that stores events. Exclusively breastfeeding women (n = 11) were assigned randomly to use each of the three methods twice during a 2-week period surrounding Weeks 4, 8, and 12 postpartum. More nursing episodes were recorded with the EM than log during Week 4 (p < 0.03) and Week 8 (p < 0.02). EM captured more episodes than recall during all study periods (p < 0.004). The EM was considered as acceptable and accurate to mothers as the other methods and, therefore, is a useful option for documenting breastfeeding patterns.

Adult↗
PubMed1982

Documenting your patient with photography in office practice.

The basic requirements for the proper photographic documentation of the foot is a single lens reflex camera, electronic flash unit, and a closeup lens set. Preoperative photographs should be a routine part of the patient workup prior to any treatment or corrective surgery. Clinical photographs should be taken with the patient standing on a plain background and should include the front, side, and back views. The electronic flash unit gives a consistent light and is well balanced with daylight color film. Surgical photographs are best taken with a telephoto macro lens or a telephoto lens with a closeup attachment. An electronic flash unit provides a consistent light. The flash unit is utilized with the AC adapter in order to give a rapid recycling and a consistent light output. Any pathological specimen should be photographed immediately following the case. Excellent specimen photographs can be taken with the use of the electronic flash held at a 30 degree angle and a sheet of white paper on the opposite of the specimen to act as a reflector. The most important aspect of the photography is to standardize the procedures so that consistent results may be obtained.

Child↗
PubMedDate not supplied

Integrated job analysis: a technique to document job activities and to identify occupational risk factors and modes of remediation and accommodation.

Integrated job analysis is a form of job evaluation that considers cognitive, physical, and environmental factors related to occupational performance, assessment, and rehabilitation. First, the analysis describes cognitive factors that determine worker interactions with data, people, and things and educational and training requirements. A task description is provided and tools used are identified, along with job physical requirements, environmental conditions, and personal protective equipment needs. Supplementary information is elicited to describe the environment, task requirements, workstations, and work areas. Based on this information, preliminary recommendations are made for abating occupational hazards, and accommodations for alternatively-challenged individuals are identified. The value of this approach is in the detailed documentation of all occupational components regarding a specific job classification, which can then guide the development of meaningful preplacement and periodic medical examinations, physical agility tests, training criteria, rehabilitation, and return-to-work regimens.

Documentation↗
PubMed2006

Documentation of patients' participation in care at the end of life.

The aim of this study was to describe how patients' participation in the care they received was documented in their health care records during the last three months of their lives. Two hundred and twenty-nine deceased adult persons were randomly identified from 12 municipalities in a Swedish county and their records were selected from different health care units. Content analysis was used to analyse the text. Four categories of patient participation were described: refusing offered care and treatments; appealing for relief; desire for everyday life; and making personal decisions. The most common way for these patients to be involved in their care at the end of their life was by refusal of the treatment and care offered. Characteristic of the different ways of participation were the diverse activities represented. The description of patients' involvement in their life situation at this time indicated their dissociation from the health care offered more than consenting to it.

Activities of Daily Living↗
PubMed2000

Chart it once: innovation in public health documentation.

The Seattle-King County Department of Public Health implemented a revision in the charting for its Family Support programs with the goal of streamlining the entire charting process, reducing redundancy, improving quality, and improving productivity. This article applies diffusion of innovations theory to the process of changing documentation.

Diffusion of Innovation↗
PubMedDate not supplied

Observation and documentation of bedside blood transfusion.

Correct administration of blood and the management of the transfused patient are a fundamental element of transfusion safety. Recently published guidelines from the British Committee for Standards in Haematology highlight that most serious transfusion complications occur within the first 15 minutes. They recommend baseline observations before and 15 minutes after commencement of each unit of blood. Using a Royal College of Physicians (RCP) proforma, 100 clinical case notes were examined retrospectively for standards of transfusion documentation and bedside observation. The audit identified that bedside practice was variable and that only 16% of cases met this standard. Most wards continued with hourly observations in uncomplicated cases. Trust guidelines and a staff education programme have been implemented to address the audit results.

Blood Transfusion↗
PubMed2004

Complex wounds: a partnership approach to patient documentation.

A concern regarding the lack of effective communication experienced within Ayrshire in relation to patients with complex wounds initiated the development of a patient-held record. The aim of the patient-held record was to promote patient empowerment by providing a method by which patients and professionals share information. Interested stakeholders worked in partnership to produce a draft record which comprises three main sections: a core section, wound section and personal notes section. Other sections which can be included, where relevant, are nutrition, continence and podiatry. After obtaining ethical approval, patients with complex wounds were involved to refine the record before participating in a successful pilot of the document. Evaluation of the pilot demonstrated that patients felt empowered and communication improved between everyone involved in the patient's care. The final record was printed with a planned, phased introduction to be undertaken across Ayrshire and Arran.

Attitude of Health Personnel↗
PubMedDate not supplied

Documentation standards set by the Clinical Negligence Scheme for Trusts.

This article considers the role of the Clinical Negligence Scheme for Trusts in encouraging the establishment of good standards of documentation in those trusts which are members of its clinical risk pool. It considers its assessment scheme, its standards for record keeping and the role of the NHS Litigation Authority.

Documentation↗
PubMed2005

Documenting changes in the delivery of substance abuse services: the Status of the "100 best treatment centers for alcoholism and drug abuse" of 1988.

This study explores the impact of managed care on the substance abuse service system by reviewing the current status of the programs that were among the elite service providers in 1988. A survey was conducted assessing the status of the one hundred centers touted as the 100 best treatment centers for alcoholism and drug abuse (Sunshine& Wright, 1988). Findings include the following: Almost a third of these centers (31%) are no longer providing services, the majority of the programs who reported data continue to provide services primarily at a residential level of care (92%); however occupancy rates have dropped, the number of annual inpatient admissions have risen, and the length of treatment episodes has significantly decreased. In 1988, almost all (97.5%) facilities adhered to the 28-day treatment regiment, as evidenced by average treatment episodes of 26 days or longer. However, in 2001, the majority of programs (57.5%) reported treatment episodes of 25 days or less. While these facilities represent a fraction of the number of facilities that provide substance abuse services, they do exemplify elite programs that should be insulated from economic troubles, and help to document the changes that have occurred in the delivery system. Awareness of these changes is important for every social worker that advocates for substance abuse services.

Alcoholism↗