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PubMed2004

Motivation for documentation.

The quality improvement plan relies on controlling quality of care through improving the process or system as a whole. Your ongoing data collection is paramount to the process of system-wide improvement and performance, enhancement of financial performance, operational performance and overall service performance and satisfaction. The threat of litigation and having to defend yourself from a claim of wrongdoing still looms every time your wheels turn. Your runsheet must serve and protect you. Look at the NFPA 1710 standard, which was enacted to serve and protect firefighters. This standard was enacted with their personal safety and well-being as the principle behind staffing requirements. At what stage of draft do you suppose the NFPA 1710 standard would be today if the relative data were collected sporadically or were not tracked for each service-related death? It may have taken many more service-related deaths to effect change for a system-wide improvement in operational performance. Every call merits documentation and data collection. Your data are catalysts for change.

Data Collection↗
PubMedDate not supplied

[New guidelines for better documentation of survey methodology and results].

Surveys of published studies on diagnostic accuracy and the performance of diagnostic tests, widely defined as any method for obtaining additional information on the health status of an individual, have revealed poor methodological quality. This holds true also for scientific journals considered to be leading in their fields. The STARD document (Standards for Reporting of Diagnostic Accuracy), which was first published in 2003, provides guidelines for the design, performance and report of such studies. Adherence to these guidelines may improve the quality of scientific publications, increased opportunities for readers to get an insight into the experimental details, improved education in medical research and increased opportunities for the disclosure of scientific fraud.

Bias↗
PubMed1992

[The optimization of patient positioning and irradiation-field documentation in irradiation in the neck-nose-throat area].

The large mobility of head and neck requires, when irradiating in this area, positioning and fastening aids, which go beyond simple head bolsters or head moulds. This paper presented describes a positioning system developed by us for irradiating the neck-nose-throat area, which, due to its construction, consists of a non-slipping positioning ground plate and an individually adjustable masking system, which is physiological safe, can be proceeded quickly and exactly, is relatively inexpensive, and is accepted by patients without objections, furthermore since skin markings by drawing field limits onto the face mask are no longer necessary. Various technical aids allow the placement of satellites to spare those body parts which are not irradiated and to install compensators for the direction of radiation. An integrated cartridge mount enables in a simple way easy production of field control documentation photos.

Documentation↗
PubMed1992

[The reality behind the bruises--clinical picture and documentation in abuse of women].

Most battered women consult for their injuries at the community health centre or the emergency room--often without disclosing the fact that they are the victims of battery. Beyond venturing to inquire, lending a sympathetic ear and being supportive, with a view to any future criminal proceedings it is particularly important that the attending physician meticulously documents all injuries manifested by a battered woman--even if at that juncture she does not intend to bring charges. If necessary the forensic pathologist can assist the clinician in drawing up a report of the injuries and in assessing their origin.

Adolescent↗
PubMed2005

Nursing outcome documentation in nursing notes of cardiac-surgery patients.

This study analyzed what nurses wrote in narrative nursing notes for nursing outcome of cardiac-surgery patients. The nursing notes of 46 patients were decomposed into phrases and analyzed based on the nursing process. Eight patterns were extracted according to different combinations of nursing-process components, of which 29.2% have nursing outcome phrases. The content of the nursing notes was also classified into 15 categories, of which nursing outcomes were recorded more frequently in nursing care driven mainly by physician's order, such as disease-related symptom management, insomnia care, respiratory care, and pain control, than in independent nursing care such as education and emotional care. A survey on the attitudes of nurses toward the nursing record revealed that they do not document nursing outcomes as much as they think they do. The main reasons for this discrepancy were insufficient time for recording and lack of knowledge about why, how, and what to evaluate. Even though there is room for improvement, nursing notes represent a useful resource for determining nursing contributions to patient outcomes.

Cardiac Surgical Procedures↗
PubMedDate not supplied

Oklahoma Nurses Association 2005 House of Delegates resolution. Intimate partner violence assessment, intervention and documentation.

Intimate Partner Violence (IPV), physical and/or sexual assault of a spouse or intimate partner, has been highly associated with severe health problems such as chronic pain, recurring central nervous system symptoms, injuries, chronic disabilities, gastrointestinal disorders, sexually transmitted diseases, gynecological disorders, unintended pregnancies, depression, substance abuse, and post traumatic stress disorder. Statistically, 40-50% of women in IPV experience both physical and sexual assault. IPV is also associated with 3-13% of pregnancies, posing a threat to health and risk of death for the mother or fetus or both from trauma. Further, 40-60% of female murders in North America are committed by intimate partners. Oklahoma ranks 13th in the nation for women murdered by men in single victim, single offender incidents. IPV associated mortality also includes suicide of women with chronic depression related to violence. Women involved with IPV utilize health care providers and the health care system 3 times more frequently than non-battered women' and generate 92% more health plan costs per year as compared to non-battered women. There is sufficient research concurrence to demonstrate a significant number of women in Oklahoma, the nation and world have severe short and long term physical and mental health effects from IPV. Some victims of IPV may turn to health care professionals for help while other victims are fearful of asking for such assistance. Therefore, it is critical that nurses, as the largest group of health care providers and often the first to come in contact with a victim of IPV, do not miss an opportunity for accurate assessment, appropriate intervention and documentation of IPV in order to provide for a safe, timely and healthy resolution.

Documentation↗
PubMed2005

Annex II technical documentation assessed.

Annex II of the Medical Device Directive (MDD) is used frequently by manufacturers to obtain CE-marking. This procedure relies on a full quality assurance system and does not require an assessment of the individual medical device by a Notified Body. An investigation into the availability and the quality of technical documentation for Annex II devices revealed severe shortcomings, which are reported here.

Documentation↗
PubMed2005

A collaborative document repository for home care teams.

Home care workers are mobile, work out of different locations, and have a high level of uncertainty in their schedules. This makes communication and information sharing difficult, and workers are often unable to account for others' activities when planning their own treatments. To address this issue, we developed and evaluated a clinical information system for home care that supports current paperwork practices and stores documents in a central repository that is accessible by all workers that treat a patient.

Cooperative Behavior↗
PubMedDate not supplied

Proof or consequences. Law to curb illegal immigrants' Medicaid coverage may sting U.S. citizens seeking medical treatment without documentation.

By requiring providers to ask Medicaid patients to prove citizenship, the government is creating a quandary: providers can comply and potentially lose millions in reimbursements or forfeit matching funds if they don't. Ironically, the mandate could cause millions of eligible patients to lose health coverage because they can't supply the documents, says Ron Pollack, left.

Birth Certificates↗
PubMed2006

Standardized documentation of drug recommendations in discharge letters--a contribution to quality management in cooperative care.

OBJECTIVES: To analyze the necessity and potential usefulness of a computerized physician order entry (CPOE) system in supporting the writing of pharmacotherapeutic recommendations in discharge letters. METHODS: Systematic analysis of drug recommendations in discharge letters of a hospital providing tertiary care, structured interviews with in-hospital prescribers, and focus groups with general practitioners who admit patients to this hospital. RESULTS: We analyzed 1800 randomly selected discharge letters, 1205 of which contained pharmacotherapeutic recommendations. The frequencies, structure, and quality of these recommendations varied considerably between departments. Nearly 16% of the recommendations contained both proprietary (brand) and non-proprietary names (active ingredient). Interviewed clinicians expressed interest in CPOE systems that check for contraindications and interactions between drugs, suggest cheaper products, and automatically insert active ingredients when omitted. The focus group sessions confirmed that the pharmacotherapeutic recommendations in current discharge letters do not effectively support daily clinical practice. CONCLUSIONS: Documenting active ingredients as well as brand names in drug therapy recommendations is currently not part of clinical practice. Computerized decision support can help to optimise the structure and communication of therapeutic information across interfaces and can be a quality factor with considerable influence on process quality, outcome quality, and costs of cooperative patient care.

Continuity of Patient Care↗
PubMed2006

Patient medication--How is it documented?

The purpose of this study was to find out how nurses use the standardized terminology of the Finnish Classification of Nursing Interventions (FiCNI) in describing their patients' medication. The main focus was on the use of the FiCNI component Medication and its various categories in daily documentation. The data were collected during a ten-month period in 2003 from electronic nursing care plans drawn up for patients of different ages (N = 1,157). The anonymous data were gathered on five psychiatric, two surgical and two medical wards, one children's intensive care unit as well as one surgical and one medical outpatient clinic at one central hospital. Data analysis was by descriptive statistical methods, and "Drug Administration per os" interventions including narrative text were further classified by means of content analysis. The main categories of the Medication component were used to describe medication administration, side effects and medication counselling. However the subcategories were more commonly used in descriptions of daily care than the main categories. Subcategories were most typically complemented with narrative descriptions of prescribed drugs, time, cause and routes of delivery.

Documentation↗
PubMed2006

Nursing documentation with NANDA and NIC in a comprehensive HIS/EPR system.

DIPS nursing documentation system facilitates that nurses can write several types of notes into the EPR. Within these notes the nurses can register NANDA diagnoses and NIC interventions with nursing activities. To choose NANDA and NIC the nurse can use a search engine, or she can choose a relevant Care plan guideline and pick the suggested diagnoses and interventions from there. Diagnoses and interventions with nursing activities registered are presented in a Care plan. When a nurse writes a note for a patient she will always be presented the Care plan and she can easy evaluate and update the Care plan.

Documentation↗
PubMed2006

Quality assurance and quality enhancement by use of digital clinical documentation.

Clinical documentation, including medical/dental history, oral status findings, treatment planning, and progress notes, are prerequisites for the use of retrospective evaluation procedures as well as for quality assessment and enhancement. A substantial condition for making full profit of these advantages of digital clinical records is that their design is based on established physiologic- and cognitive-ergonomic concepts.

Cognition↗
PubMed1991

[International documentation system for colorectal cancer-- reporting pathological findings].

An international Working Party has achieved agreement on an "International Documentation System for Colorectal Cancer (IDS for CRC)". It includes the essential clinical and pathological data required for estimation of prognosis and evaluation of treatment results. These data are subdivided into 3 types of information: (i) basic patient information; (ii) variables of proven prognostic significance (anatomical extent of disease, i.e. pTNM, and residual tumor classification, some other independent variables); and (iii) information of probable prognostic significance. Recommendations for data collection, pathological techniques and reporting pathology are added.

Colonic Neoplasms↗
PubMedDate not supplied

A comparison of four nursing documentation systems.

Nurses must be able to keep charts effectively and efficiently while providing high-quality care. Often, nurse educators are responsible for finding a workable system for a particular institution. This article reviews four nursing documentation systems that can be used in a variety of health care settings: Problem Centered, PIE (Problem Intervention Evaluation), Focus, and Charting by Exception.

Documentation↗
PubMed1991

[New information technologies in the keeping, recording and processing of medical documentation based on personal computers].

The main methods of organizing the information technology for medical documentation keeping, registration and processing are considered. Suggestions are made of a new information technology which expects to make use of personal computers and is based on built-in logical trees of various medico-biological information most frequently used in the department of the given profile. A description is provided of the first version of the system which is realizing the technology on IBM PC HT/AT computer.

Documentation↗
PubMed1991

Documentation. A focus for cost savings.

Documentation typically is an area that can be streamlined, thereby saving nursing time and money. The authors' nursing division created a combination intervention record and nursing progress notes form for a 24-hour period. The results yielded a savings of 90 minutes of RN time in a 24-hours period, a 36% reduction in charting time, and an annual cost savings of $437,000.

Cost-Benefit Analysis↗