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At least 1,693 records · Page 94Linked to original sources
PubMed1999

[Correct documentation of drug prescriptions].

The present study was undertaken to investigate and minimize possible differences in doctors' and nurses' documentation of drug prescriptions. A retrospective medical audit including 100 patients receiving medication revealed 69% correct prescriptions in doctors' case records. Only 44% of prescriptions in nurses' drug lists were correct. Based on the exposed problems a prescription sheet and clinical guidelines for medication were developed and implemented in the department. This resulted in 91% correct prescriptions in a comparable group of 100 patients receiving medication, a highly significant improvement. Among prescriptions signed by a doctor as legally requested, 98% were correct. The prescription sheet also served as an updated survey of medication. No health-threatening prescription errors were disclosed in either group. In conclusion, a common prescription sheet significantly improved the quality of drug prescriptions.

Denmark↗
PubMed1999

Easing the switch to medical necessity documentation.

The responsibility for educating clinicians on Medicare's new regulations for test coding and documentation has fallen to the nation's laboratories. See how this reference laboratory created its own tools to help them cope.

Clinical Laboratory Techniques↗
PubMed1999

[Optimizing performance documentation in gynecology--assistance from the internet].

The documentation of operations in the field of gynecology and obstetrics is regulated by social laws in Germany. Only by optimal encoding of diagnoses and procedures an efficient cashing with the health insurance's can be achieved. This requires profound knowledge of the invoice modalities and usually support by computer systems. The Internet offers in this respect some assistance, which in the following is pointed out and evaluated critically.

Documentation↗
PubMed1975

[Documentation and physician's letter by means of modern data processing].

When starting our surgical out-patient department at the Hannover Medical School we were forced to computerize our medical correspondence as far as possible. In cooperation with the department of biometrics of the Hannover Medical School, a set of three computerized forms was established which in addition to facilitating medical correspondence enabled systematic documentation. The FTSS system generally used in the computer language PL/1 was used for computerization of our forms.

Documentation↗
PubMed1999

Here are key revisions to documentation guidelines.

ED reimbursement experts say the new documentation guidelines proposed by the Health Care Financing Administration will be easier to comply with. For a comprehensive history, only five organ systems are required to be reviewed, not 10. Instead of organ systems, the number of physical exam elements now includes individual components of those systems. It will be easier to identify the level of history if the patient is unable to give an adequate history.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2000

Using handheld computers to document family practice resident procedure experience.

BACKGROUND AND OBJECTIVES: We examined the use of inexpensive handheld computers in documenting resident procedures. With a handheld computer, data is entered at the time of the procedure, eliminating the problem of double entry. METHODS: Connectivity and ease of use were important factors considered when choosing a handheld computer. All residents received a handheld computer for data entry. Residency staff downloaded the data to a desktop computer. At the same time, data useful to residents was placed on their devices. The process of generating individual and program reports required 2 hours of staff time each month. Survey data regarding use and acceptance by residents was collected. RESULTS: Eighty-eight percent of residents collected data on their handheld computer. Those residents responding to a survey felt that the handheld computer was "very useful," and 73% reported daily use. Initial costs were $310 per resident. CONCLUSIONS: Handheld computers streamlined the collection of procedure data for family practice residents. Handheld computers assisted in producing timely and useful procedural reports for both residents and the residency program. Additional uses of handheld computers were beneficial to the program and the residents.

Computers↗
PubMed1999

Document versus data centred approach to the EPR.

This paper presents the document centred Electronic Patient Record (EPR) as currently in production in a large university hospital and subject to multiple additional developments in the coming years. A number of basic hypothesis have been developed in order to reach the best medical practice and the success of this application. In addition, the alternative approach of data centred EPR is compared, and different benefits and pitfalls are highlighted. It is not easy to evaluate the consequences of such an initial trend, but changing one's mind after having a system in daily production is anyway costly and difficult. Therefore, the selection of the right orientation in a given hospital necessitates a scientific debate.

Data Collection↗
PubMed1999

Effective multidisciplinary communication in healthcare: cooperative documentation systems.

To support multidisciplinary communication and cooperation in healthcare, cooperative documentation systems (CDSs) have been developed. However, in the current generation of systems, communication problems that can pose a serious threat to smooth and effective cooperation have occurred and remain to be addressed. This paper presents a set of features that need to be considered in the design of a new generation of CDSs to avoid breakdowns in communication and cooperation. Our approach is solidly grounded in linguistic and social theories and based on empirical investigations of communication patterns in multidisciplinary healthcare. It is argued that this work provides a theoretically rigorous approach to the design of CDSs that will enable effective multidisciplinary communication and cooperation in healthcare.

Communication↗
PubMed2000

[Patient centered medicine--a review with emphasis on the background and documentation].

BACKGROUND: In this paper we present the patient centred clinical method from a historical viewpoint with emphasis on its philosophical and ethical foundations. The paper reviews the documentation and discusses the relevance of the method. MATERIAL AND METHODS: Literature review. RESULTS: The patient centred method was introduced in western clinical medicine as a result of a general shift in science and the introduction of systems theory and relational understanding. The ethical basis for the method is humanistic values with emphasis on respect and mutuality in human relations. Observational studies suggest that the method improves outcome for patients. Experimental evidence is sparse and conflicting. The concept of patient centredness is vague with regard to the management phase of consultations. The relationship between doctor-patient communication, the concept of patient centredness, patient satisfaction, empowerment and outcome needs further clarification and research. INTERPRETATION: Clinical medicine has to encompass the personal and relational level of human life in order to help and guide patients. The patient centred method demonstrates how this can be achieved during the diagnostic phase of the consultation. We need, however, firmer knowledge and ethical consideration of how management negotiations may empower patients and improve their outcome.

Communication↗
PubMed2000

Planning documents: a business planning strategy.

Strategic planning and business plan development are essential nursing management skills in today's competitive, fast paced, continually changing health care environment. Even in times of great uncertainty, nurse managers need to plan and forecast for the future. A well-written business plan allows nurse managers to communicate their expertise and proactively contribute to the programmatic decisions and changes occurring within their patient population or service area. This article presents the use of planning documents as a practical, strategic business planning strategy. Although the model addresses orthopedic services specifically, nurse managers can gain an understanding and working knowledge of planning concepts that can be applied to all patient populations.

Commerce↗
PubMedDate not supplied

Documenting patterns of nursing interventions using cluster analysis.

Use of inferential statistics in research applications of the Nursing Intervention Classification has been rare, yet use of these statistical techniques is needed to answer questions related to intervention patterns. Using data from a descriptive study of 3,733 visits documented by 19 adult nurse practitioner students, hierarchical agglomerative cluster analysis was used to determine whether meaningful nursing intervention patterns could be depicted. Eight intervention clusters were derived, replicated, and validated. Clusters of intervention classes differed in the type of nursing and medical diagnosis, amount of time the nurse spent during the visit, cost of visit, and the age of the patient. Clustering supported the utility of standardized nursing diagnosis and intervention typologies to identify actual practice patterns of adult nurse practitioner students. Cluster analysis is a valuable data analysis strategy when analyzing multiple related variables.

Adolescent↗
PubMedDate not supplied

Incorporating family and social structures into clinical documentation and retrieval.

Referencing familial and social relationships between patients supplies valuable information for the retrieval and interpretation of clinical data. We present a technique for the incorporation of patient relations into data retrieval that takes into account the specific properties of routinely collected clinical data. In most clinical databases, family relations are documented in a fragmentary manner at best. Furthermore, clinical retrieval systems do not support inter-patient queries in most cases. Our model is designed to formulate direct relations between patients and to identify patients as members of either temporary or persistent communities. In this way, the model supplies information on both genetic and social relations.

Consanguinity↗
PubMed2002

[The cynical game of the tobacco industry. Many years' efforts to deny or cover-up the negative effects of tobacco are revealed by the forced publication of internal documents].

Scrutiny of internal tobacco industry documents, now available on the Internet, reveals that Sweden and Finland were classified as "priority 1" areas in which to intensify efforts to resist tobacco control measures. In the late 1980s Philip Morris increased its activities in Scandinavia in order to counteract penal taxation threats and marketing restrictions. Swedish scientists were engaged by the tobacco industry in the "White Coat" project, a program expected to shed doubt on research linking passive smoking to health risks. The Swedish tobacco company Swedish Match collaborated with Philip Morris in challenging measures to limit tobacco use, including the new, stricter tobacco law proposed in the early 1990s.

Conflict of Interest↗
PubMedDate not supplied

[Assessment and improvement of the quality of nursing documentation].

The article proposes a method to verify and to improve the quality and the effectiveness of the working tools. Inside those, Authors believe essential to run out paths for revision and development of quality including projects for the evaluation and the improvement of nursing documentation considering it as an essential start to continuously modify and improve nursing care practically. The article introduces a possible example of intervention with the aim to produce, inside the professional community, a constant awareness on quality outcomes of our caring for the benefit and improvement of the quality of life of our clients.

Documentation↗
PubMed2002

Documentation of training: developing essential records.

In response to the need for proper documentation of training given to security officers to insure that training had actually been given and to better achieve training standardization, two types of forms have been developed by a security department at a medical center.

Competency-Based Education↗
PubMed2002

[Prescribing and dispensing drugs in Denmark. Frequency of and intervention against errors in documentation and dispensing of drugs].

Foreign studies mainly describe errors in medicine prescriptions in context with adverse drug events unlike most Danish studies and projects, which focus on documentation. Current methods of prescribing medicines in Denmark only partially follow the guidelines given by the National Board of Health. About two thirds of the prescriptions are unambiguous. Errors of potential clinical significance are estimated to occur in 4.5% of prescriptions. Transcription errors occur mainly from patients' records to the medication forms and are found in 23% to 83% of transcribed prescriptions. Several departments have intervened by using only one prescription form, a paper or electronic version, which reduced the number of ambiguous prescriptions and eliminated transcription errors. Dispensing errors are common and demonstrate the importance of further quality improvement.

Adverse Drug Reaction Reporting Systems↗
PubMed1992

Visual documentation of neoplasms as part of the REGISTRY Nomenclature Information System.

The REGISTRY Nomenclature Information system (RENI) is a program which runs on IBM-compatible personal computers. It includes internationally accepted diagnostic criteria for tumors and pre-neoplastic lesions in the rat to be used in toxicologic pathology. A video disk system, connected to the computer, provides colored pictures of histopathological reference slides, which are used for a visual documentation of the written criteria.

Animals↗