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PubMed1994

Prostitutes in the archives: problems and possibilities in documenting the history of sexuality.

In the past decade, the study of sexuality has proven to be one of the most dynamic academic enterprises. Among the most popular topics has been the history of prostitution. Archivists have been invaluable but largely unsung allies in the explosive growth of a new revisionist literature. Through the preservation of long-ignored and often-discarded records and manuscripts, archivists provided the means enabling historians to answer many new questions, not only about prostitution but about the history of sexuality. Yet some of these sources raise provocative and controversial problems for historians and archivists documenting the history of sexuality. The author acknowledges and thanks Loyola University of Chicago, the National Endowment for the Humanities, and the Newberry Library in Chicago for providing financial support to complete this article. His appreciation also extends to Mary Rose Alexander, Kenneth Cobb, Phillip Costello, and the anonymous referees of The American Archivist for their criticism and helpful comments on earlier drafts.

Archives↗

PubMed1991

Effectiveness of source documents for identifying fatal occupational injuries: a synthesis of studies.

BACKGROUND: The complete and accurate identification of fatal occupational injuries among the US work force is an important first step in developing work injury prevention efforts. Numerous sources of information, such as death certificates, Workers' Compensation files, Occupational Safety and Health Administration (OSHA) files, medical examiner records, state health and labor department reports, and various combinations of these, have been used to identify cases of work-related fatal injuries. Recent studies have questioned the effectiveness of these sources for identifying such cases. METHODS: At least 10 studies have used multiple sources to define the universe of fatal work injuries within a state and to determine the capture rates, or proportion of the universe identified, by each source. Results of these studies, which are not all available in published literature, are summarized here in a format that allows researchers to readily compare the ascertainment capabilities of the sources. RESULTS: The overall average capture rates of sources were as follows: death certificates, 81%; medical examiner records, 61%; Workers' Compensation reports, 57%; and OSHA reports 32%. Variations by state and value added through the use of multiple sources are presented and discussed. CONCLUSIONS: This meta-analysis of 10 state-based studies summarizes the effectiveness of various source documents for capturing cases of fatal occupational injuries to help researchers make informed decisions when designing occupational injury surveillance systems.

Accidents, Occupational↗

PubMed1993

Guidelines for economic analysis of pharmaceutical products: a draft document for Ontario and Canada.

In Canada, provincial formulary review committees consider the effectiveness, safety, and cost of products when they derive advice for each Minister of Health. This article offers a draft set of guidelines for pharmaceutical manufacturers making submissions which include economic information, moving beyond a simple presentation of the unit price of the pharmaceutical product (e.g. price per day or course of therapy) and comparison to similar prices for alternative products. A full economic analysis compares all relevant costs and clinical outcomes of the new product with alternate therapeutic strategies for treating patients with a particular condition. The perspective of the decision maker must be clearly identified. The quality of the evidence supporting estimates of the variables incorporated in the analysis should be evaluated. Sensitivity analyses are used to assess the robustness of the qualitative conclusions. Reviewers will examine the answers to a set of 19 questions. Manufacturers can use these questions as a worksheet for preparation of an economic analysis to be incorporated in a submission. These guidelines are intended to be a starting point for further refinement, and discussion with health economists in industry and academia. Considerable flexibility will be used in reviewing documentation supporting economic analysis. Those preparing submissions should be encouraged to experiment with various approaches as part of the general development of this field and to engage provincial review committees in ongoing discussions.

Canada↗

PubMed1993

Three-dimensional Hi-vision system for microneurosurgical documentation based on wide-vision telepresence system using one camera and one monitor.

A three-dimensional (3-D) high-definition television (Hi-Vision) system suitable for attachment to a stereoscopic operating microscope allowing 3-D medical documentation using one Hi-Vision camera and one Hi-Vision monitor is described. The system provides 3-D high-definition microneurosurgical recorded images suitable for viewing on a screen or monitor, or for printing.

Documentation↗

PubMed2002

Tainted love: content analysis of documents written by accused spousal abusers to their victims.

This study analyzed themes in documents written by 22 male accused spousal abusers to their female victims. Using Pence's Power and Equity model (1998), 86% of the themes denied equity and expressed power and control in the relation. Of these, 28% minimized or denied the abuse, 24% used the children to manipulate the victim, 16% showed disrespect for the victim, and 14% invoked male privilege (including God's ordination of the abusive relation). These hallmarks of tainted love are rooted in the desire of the accused abuser to maintain power and control over the victim.

Adult↗

PubMedDate not supplied

Building a cytology report database: a computer-assisted system for documentation, evaluation and hospital-wide recall of haematological biopsy reports.

Owing to an increasing number of biopsies from different organ systems in our institution and referring institutions there was need to develop a computer-based system to improve documentation, analysis and reports of pathological findings, as well as speed of transmission of information in a clinical haematology/oncology unit. As terminals connected to a central minicomputer are located on all wards of our hospital, we have now provided a faster way of moving information from the cytology reporting site to all hospital departments. Using the hospital's minicomputer we developed an easy-to-use system based on five different codes for each cytological specimen: organ biopsied, quality of specimen, cytological diagnosis including information as to status of patient (i.e. pretherapy), and an additional code describing the degree of remission obtained after chemotherapy of acute leukemias. After microscopic analysis of the specimen these five codes are read into a terminal; minutes after the diagnosis is made, a short version of the report can be accessed from all wards in the hospital.

Biopsy↗

PubMed1992

Improving documentation of aggressive behavior in nursing home residents.

1. Although 66% of the 1.3 million elderly nursing home residents in the US exhibit aggressive tendencies, research indicates that caregivers underdocument aggressive incidents. As a result, the extent of aggression is unknown. 2. This study found that LPNs reported the largest percentage (41%) of the 51 documented aggressive incidents, which reportedly occurred most frequently in the bathroom (49% of the time) between 5 AM and noon (86% of the time). Most aggressive residents (55.1%) never had visitors. 3. This study concludes that nursing practice would benefit from a consistent definition of aggression, an easy-to-use clinical instrument to collect data on aggression, and caregiver education programs on assessing aggression.

Aged↗

PubMed1994

Risk for abuse/neglect: documentation of assessment data and diagnoses.

1. Elder abuse/neglect is becoming an increasing problem in our society. It is estimated that 1.5 million individuals are victims of elder abuse or mistreatment every year, with only one in five cases reported. 2. Despite the increased concern for elder abuse/neglect, there is a lack of research in the area of charting on adult vulnerability and risk for abuse/neglect. 3. Information sharing, increased awareness, education, and adding areas of notation on the chart or care plan appear to be helpful in increasing the documentation on adult vulnerability.

Aged↗

PubMed1989

A medical review approach to Medicare outpatient documentation.

Blue Cross of California has recognized the problem of reimbursement delays due to Medicare claims that have been returned or denied. The information in this article applies to the medical review process and suggests an interpretation of the new Medicare outpatient guidelines used by the Blue Cross of California Medicare reviewers. As a solution to the problem of delayed reimbursement, medical reviewers--who are also practicing occupational therapists--offer an explanation of the Medicare review process and suggestions for correcting technical billing errors. Methods for keeping complete and timely medical records are discussed, with the suggestion that clinicians follow these methods from the start of care. A process for documentation is presented that will clearly prove to the medical reviewer the need for the special skills of an occupational therapist. This article also proposes reasons for noncoverage because of insufficient medical necessity. It is important to note, however, that variance between fiscal intermediaries' interpretations and requirements exists nationwide. This article, therefore, represents only one fiscal intermediary's approach to reviewing claims and medical records.

Ambulatory Care↗

PubMed1993

Computer-assisted functional assessment and documentation.

Occupational therapy personnel spend considerable time on functional assessment and documentation. The rapid and error-free information processing ability of computers offers methods for data collection, clinical decision making, and reporting of functional assessment results, which may be more effective and efficient than the current paper-and-pencil methods. Computers can provide assistance throughout the many steps of the functional assessment and reporting process. Software is available to assist in direct data collection, data reduction, and analysis, or to assess complex data systems and databases. Additionally, computers can use assessment techniques, such as dynamic question sets and expert systems, which have not been possible with paper-and-pencil methods. Furthermore, data collected on computers are readily available to be integrated in computer-assisted report writing and can be compiled into large databases for analysis. These databases can be used for program evaluation, continuous quality improvement exercises, and other research objectives. This paper provides a snapshot of these computer uses in the assessment process.

Computers↗

PubMed2001

Linking nursing pain assessment, decision-making and documentation.

A clinical nurse specialist's (CNS) experience in the development and implementation of a pain assessment and treatment flowsheet (PATF) to enhance the nursing assessment, decision-making, and documentation of pain on a palliative care unit in a community hospital is described in this article. Members of the palliative care interdisciplinary team use the PATF for clinical decision-making in the day-to-day management of patients' pain. The PATF is undergoing revision and re-implementation to promote the utilization of the tool beyond the specialty of palliative care and into the general patient population.

Decision Making↗

PubMed2004

Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.

Adverse drug events cause substantial morbidity and mortality, yet they remain underappreciated and misunderstood. The terminology to describe errors and patient harm associated with medications causes much confusion. This article uses the case study of a patient with multiple adverse drug events to clarify key terms, such as adverse event, adverse drug reaction, adverse drug event, medication error, and side effect. The case discussion illustrates clinical approaches to analyzing the causal connection between a suspect drug and an adverse event. Examples and rationale for meaningful documentation of adverse drug events are provided, along with an outline of the types of events that should be reported to regulatory agencies.

Adverse Drug Reaction Reporting Systems↗

PubMed1999

[Bodily evidence can reveal torture. 5-year experience of torture documentation].

At the Centre for Torture and Trauma Survivors in Stockholm, 201 subjects from 34 countries were documented during a period of five years. Torture reports differed little between individuals from the same countries or regions, regarding methods and circumstances. Africans from Uganda (n = 22) reported brutal torture and manifested extensive scarring (mean number of scars, 20; range 4-65), whereas subjects from Syria (n = 28) reported falaka (i.e., bastinade), whipping and suspension, but manifested few or no scars (mean number 5, range 0-17). Of the subjects examined, 17% were women, of whom 79% reported having been raped during torture. Chronic back pain was the most common complaint at the time of examination. Correlation was found to exist between sexual torture and genito-urinary symptoms, bastinade and neural symptoms, and electrical torture and symptoms from the joints and gastro-intestinal tract. Severity of physical torture was a correlate of post-traumatic stress disorder. However, the forensic report had no effect on the verdict of immigration authorities regarding individual asylum applications.

Adolescent↗

PubMed1999

[Abbreviated Psychopathological Scale in basic documentation in child and adolescent psychiatry--results of a multicenter study].

The short form of the Clinical Assessment Scale of Child and Adolescent Psychopathology (CASCAP) assesses psychopathological features only on the level of symptom domains and not on the level of single symptoms. The instrument is part of the basic documentation of child and adolescent psychiatry. Based on the multicenter study sample of CASCAP the ratings of the symptom domains in the different centers were analysed. Inpatients receive higher ratings than outpatients on nearly all symptom domains. Only minor differences could be found between the centres. Advantages and disadvantages of this short version are discussed.

Adolescent↗

PubMed1991

The financial burden of Medicare documentation in home care.

The Health Care Financing Administration 485/486 forms constitute the greatest paperwork burden for most agencies. This article suggests a method for analysis of the amount of resources consumed in the 485/486 process and estimates labor costs incurred to produce these documents.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1991

Twenty-four-hour controlled substance documentation system: the optimal way to monitor use in the nursing units.

Accountability for the use of controlled substances in the nursing units is a top priority for nursing and pharmacy administration in any health-care institution. After several discrepancies were found in inventory at the John F. Kennedy Memorial Hospital in Indio, California, the pharmacy department revised the controlled substance handling system in the hospital and implemented a 24-hour controlled substance recording system. The system provided greater accountability and allowed follow-up on any discrepancy within the next shift. The system has been highly successful. There had been six discrepancies in 12 months before implementing the system. There has been no incident of discrepancy in the last 31 months. The authors conclude that 24-hour controlled substance documentation system is very effective in providing greater accountability and control over controlled substance use in the nursing units.

California↗

PubMed1991

Documentation of pharmacist interventions in a decentralized unit dose system.

The purpose of this study was to justify the increased costs of providing decentralized pharmacy service by defining therapeutic interventions as they relate to improved patient care and by documenting cost savings generated by decentralized pharmacist interventions. Data were collected on a daily basis from information provided by the decentralized pharmacists using a daily worksheet. The various interventions were then categorized as cost-saving interventions and therapeutic interventions. Decentralized pharmacist interventions do provide important therapeutic interventions as well as cost-effective interventions. The total cost-saving interventions in 1989 was $126,509 and this included the automatic drug conversions. The pharmacists also provided 2506 therapeutic interventions.

Centralized Hospital Services↗

PubMed1991

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); medical documentation--Department of Defense. Final rule.

This final rule amends DoD 6010.8-R (32 CFR part 199) which implements the Civilian Health and Medical Program of the Uniformed Services. The final rule clarifies and strengthens medical documentation requirements under the CHAMPUS. This will assist in the maintenance of an adequate level of quality care and help ensure that payment is made only for services rendered.

Documentation↗