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A simple, accurate, and inexpensive method of documenting metatarsus adductus involves taking photocopies of the foot in the weightbearing position. Subsequently, treatment progress can be assessed objectively by reviewing serial photocopies. Some caution is urged because the strength of the glass copying surface of photocopying machines is unknown.
The documentation of restraints in a psychiatric hospital was examined over the period of a year as regards frequency and duration of restraints as well as the reasons for them. Based upon this statistical evaluation, the conditions which lead to the use of force in psychiatry are discussed in general, taking into account disease-related causes and--above all--institutional and environmental factors as well as causes related to interaction. Final considerations investigate if and how an increase in staff and concrete support for the everyday running of a ward can diminish the potential for violence, thus rendering restraints unnecessary as far as possible.
A generally accepted classification and documentation for cerebrovascular insufficiency are needed to eliminate controversies and misinterpretation in clinical studies on the spontaneous course of the disease and the outcome of patients receiving surgical or conservative treatment. The author proposes a clinical classification (stages I to IV) based on the affected vascular territory (A, B, C). The following findings should be included: 1. the number of diseased extracranial arteries (I to IV vessel disease), 2. the presence of ischemic brain lesions (CT, SPECT, RMI), 3. concomitant diseases or risk factors (hypertension, coronary heart disease etc.). Such morphological and functional staging makes possible the selection of comparable groups of patients for investigation.
In a Pharmaceutical Industry Research Center requirements in statistics and data processing are: data acquisition and management, clinical trials management, clinical trials accomplishment, computation and statistics. Authors explain the choice they have made to develop softwares by themselves. They review software functions and insist on maintenance and documentation and also on internal education procedures necessary for their implementation and using.
Nursing managers and staff RNs must work together to manage documentation costs. The FACT Charting system realized one-time savings of approximately $500,000 through the redesign of repetitive, redundant forms and through increased efficiency using flow sheets and concise narrative notes.
In recent years, several cases of scientific fraud have been published in USA and UK. This underscores the need of better documentation of research data. We here propose a brief set of guidelines. The Danish Medical Researched Council has appointed a committee working on the problems of scientific misconduct.
A computerized documentation system for upper gastrointestinal endoscopy is described. It is easy and convenient to use. Data are continuously monitored and endoscopy records automatically regenerated. Records of previous examinations are rapidly retrieved and printed. Basic statistics are integrated.
The problems of alcoholism and drug addiction are major concerns in India. Alcohol and drugs were used in the past to obtain relief from pain and misery and to attain a state of forgetfulness. India is presently facing the problem of increased trafficking in drugs; heroin and hashish are supplied to the west through the subcontinent. Addiction has become a major problem in metropolitan centers. The Ministry of Welfare is responsible for drug abuse prevention programs and the rehabilitation of addicts. The Ministry of Health and Family Welfare is concerned with drug treatment. A deaddiction center, established at the All India Institute of Medical Sciences, became operational in 1988; it is responsible for health manpower training, research, and documentation. India has witnessed an exponential growth in the literature on drug abuse; it is no longer possible for a single library to acquire all of the international literature. There is a clear need to establish a drug abuse information center in India. This paper describes the aims, objectives, and planning for such a center and recommends the establishment of a national center in New Delhi with regional centers in other geographic areas.
This paper reviews an approach to the evaluation and documentation of suspected adverse drug reaction (ADR). I propose an algorithm for the evaluation of suspected ADR. I recommend that the adverse drug reaction scoring system(ASS) or the adverse drug reactions probability scale(APS) be used when evaluating suspected ADR. In these two scoring systems, points are allotted according to response to a series of questions on events relating to the clinical manifestations of the suspected ADR. Depending on the total points scored the probability of the suspected ADR are classified as definite, probable, possible and unlikely. When a patient's suspected ADR is classified as definite, then no further investigation is necessary. The patient should be considered sensitive to the drug. In a case where the suspected ADR is classified as probable or possible then further investigations should be considered to confirm the diagnosis. If the nature of ADR is life threatening only in-vitro test should be done. If the nature of ADR is not life threatening, in-vivo and oral provocative test dosing may be considered. It should be considered if the suspected drug in question cannot be substituted and when it is very frequently prescribed.
The analysis of 311 death certificates of stillbirths and live born under one year of age covering the period from 1979 to 1984 and the analysis of the clinical dates referring to revealed: a high frequency of mistakes both in the nondiagnostic and in the diagnostic part, the handling of the documents was not in correspondence with the law, the number of mistakes in the nondiagnostic part has decreased, obstetricians made more mistakes than pediatrists, physicians with great experience in the field of death certificates made less mistakes, the number of secundinae to be morphologically investigated was to low and the possibility of corrections of the cause of death was not made use of. To improve the situation recommendations are given.
We report on a data base system for general registration including blood alcohol results which is in operation at the Institute of Forensic Medicine at Heidelberg University since january 1987. It is run on personal computers using dBase III plus as data base software. Working with the system has been adapted to the mode of operation hitherto. It's main purpose is to offer a general mean to standardize the documentation of results in the different fields of forensic medicine. At present it is run parallel with the registration by means of hand-written books. It's main advantage is the rapid search for all occurring names and files. Blood alcohol results are typed at the screen and printed out on the institute's standard form, with the expert's opinion being composed of text blocks. The essential data are extracted and transferred to the data base. A network of personal computers at different locations in the institute will be installed in the near future. A print-out of the data base will replace the hand-written registration, and the registration files will be completed by result files.
At the instance of the chronic liver diseases (Nr. 571 and 573 IKK) is shown in form of a model which high value of information the process of the stored data of the headline of a medical record suited for documentation. Thus informations concerning the clinical morbidity/mortality, analyses according to age and sex, residence and admitting institution, comparison of admission, treatment and post-mortem diagnoses, ascertainment of the diagnosis and finally economic data may be got. From this result the epidemiological conclusions and the statements for analyses of factors.
The purpose of this study was to establish a profile of the amount of time expended by clinical dietitians in providing nutrition services. One hundred twenty-seven dietitians in 49 hospitals in Texas collected time data according to nutrition care activity, diet order classification, care level, and diagnosis. Frequency, mean time, standard deviation, and percentage of time were computed for each of the variables. Data were analyzed to ascertain relationships among the variables. The dietitians expended 50.7% of their time performing client-related activities, 9.8% in administrative/managerial functions, 1.0% in professional activities, 5.1% in non-professional activities, 14.0% in delay activities, and 19.5% in transit time. The diet order classification that required the largest amount of the dietitians' time according to selected components of the nutrition care process was the calorie-controlled diabetic diet. Among the four nutrition care levels, dietitians expended the greatest percentages of time providing services for patients requiring intermediate (35.4%) and advanced intermediate care (30.4%). Dietitians expended more time providing client-related activities to patients diagnosed with diseases and disorders of the endocrine and excretory systems than to other patients. Mean times provide the clinical manager with documentation for determining staffing needs and costs of services.
The methods of data collection, storage, and retrieval used by the Rocky Mountain Drug Consultation Center (RMDCC) are described. To substantiate that drug information services provided by RMDCC are clinically useful and have a beneficial effect on therapy, data on medication-related problems and case outcomes, as well as demographic data, are stored in an IBM PC-XT using a system that allows searching and linkage of any number of recorded categories. Data were compiled on 28,081 inquiries from health-care professionals and consumers during 1985 and 1986. Analysis revealed that (1) medication-related problems are common (involving 34% of consumer inquiries), especially among the elderly; (2) a positive effect on therapy was made in the majority (76%) of problem cases; and (3) consumers were given drug information by their physician or pharmacist in fewer than half of the cases in which medications were prescribed and dispensed. A computer-based system to assist in analyzing information can be an important asset in documenting the activity and effectiveness of a regional drug information center.
All patients who had undergone general surgery in three different periods of time were prospectively recorded. Results were found to have been improving with significance owing to peri-operative antibiotic prophylaxis, mechanical suturing (for gastro-intestinal anastomoses), and introduction of a system of regular documentation. Rates of postoperative complications were also affected by the individual surgeon's efficiency and techniques.
The following conclusions were drawn from analysis of 292 specimens of amputated female breasts and statistical evaluation of the clinical data: Preparation of lymph nodes from unfixed material should be left to medical preparation engineers. All data on sizes and numbers should be recorded for documentation with high accuracy. Communication of clinical data has often been insufficient. It has happened all too often that no diagnostic extirpation was undertaken, and the time interval between such extirpation and radical surgery was found to be too long in some hospitals.
Few nursing divisions can withstand the continuation of practices known to be ineffective and costly, and of questioned benefit. Our hospital's critical survey of policies and procedures regarding nursing documentation has resulted in significant cost savings and improvement in satisfaction and quality.
As the only international classification scheme the TNM-system allows classification of practically all tumours of all organs according to uniform rules. In the interest of international comparison of findings and results the TNM-system alone can be recommended for classification. Checklists are used for extension of the basic documentation for the head and neck. Directions for initial and follow up analysis are given. The TNM-system in this proposed practice allows clear determination of the pre-therapeutic findings, recurrences to be taken into account, the course of the disease to be recorded, and the survival rate to be calculated. The data are suitable for recording on a computer. Finally uniform recommendations for treatment may be deduced.