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PubMed1993

[Documentation of injuries].

The expert assessment of injuries due to criminal offenses is of great importance for any later legal proceedings. The initial medical examination of severe lesions is very often performed by clinicians; however, and when it which must be surgically shows that immediate surgical treatment is indicated later forensic interpretation is only possible if precise records documenting the nature of the wounds have been kept by the first doctor involved. The most frequent patterns of these injuries and relevant forensic aspects are discussed.

Documentation↗
PubMedDate not supplied

Prototyping a bedside documentation system.

The implementation of a comprehensive bedside documentation system is a major project that demands careful analysis and planning. Since the cost of a typical bedside system can easily exceed $3 million, a design oversight could have disastrous effects on the benefits of the system.

Computer Systems↗
PubMed1993

Voice-activated nursing documentation: on the cutting edge.

In a large, eastern medical center, nurses introduce voice-activated software programs for high-volume patients with similar conditions to economize documentation time and to improve the quality. Early results show remarkable savings in time and energy.

Documentation↗
PubMed1993

Rural hospitals set the pace for computerized documentation?

Automated documentation for rural health organizations can be prohibitively expensive. A system is described which can integrate existing admission, discharge and transfer systems. Using "pen pads" permits bedside automation without the capital cost of bedside computer terminals. Both improved patient care and nursing staff satisfaction should result.

Documentation↗
PubMed1993

[Structured documentation of findings and user acceptance--results of a study of abdominal ultrasound].

Structured reporting of medical findings is known to have positive effects on data quality, whereas user acceptance tends to be low because of time requirements. This paper presents the results of a survey among 19 physicians who worked for 14 months with a computer system using structured data input for abdominal ultrasonography. During this time, they prepared 8.827 reports. The two most important results are that it is feasible to realize well accepted documentation systems with high data quality by using modern computer technology, and that graphic user interfaces tend to increase user acceptance. For comparable systems, evaluation studies are suggested.

Attitude of Health Personnel↗
PubMed1995

Documentation in endoscopy.

The use of video monitoring and imaging techniques have enhanced endoscopic documentation. Conventional photographic techniques using 35-mm photography produce excellent quality images but are cumbersome for routine use. Electronic images can be recorded on videotape or printed, and they can be stored electronically on computer or disk.

Compact Disks↗
PubMed1995

[Overview, analysis and evaluation of the 1995 public health structural law and the federal social care law from the viewpoint of the trauma surgery department of a university clinic. Measures for preparation of a new reimbursement system and documentation requirements].

All doctors in Germany are required to cooperate in the implementation of the health system reform and the new system for reimbursement of the hospitals to limit the negative consequences to the patients. It would be absolutely wrong to leave the medical services of the insurance companies to define the diagnosis-related groups and determine the charges. The revision of the health system is beneficial in that it supports the economical independence of hospital departments. It is a good idea for them to be paid by results; however, there are no established methods of measuring results or efficacy in medicine. Germany is about 10 years behind the USA in this, so that our country is not yet ready for this reform. Hospital departments do have the freedom to make economic decisions, being heavily dependent on the insurances and the government, because most people who work in hospital are paid from these sources. Departments of trauma or orthopaedic surgery are disadvantaged by the reform, because of the number and kind of diagnosis related groups and the method of reimbursement. This leads to a profit-oriented system of medical documentation, with possible upcoding of diagnoses in future. The present health reform most probably will not increase the efficiency of hospitals; it will not be possible to attain cost reductions with the same level of medical care. The reduced reimbursement will force doctors to cut down their expenses and restrict diagnostic and therapeutic procedures. On the other hand the administration sector in hospitals and insurances will expand dramatically in future.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Control↗
PubMed1995

On-line documentation of patient care orders.

The INFORMM NIS (Information Network For Online Retrieval & Medical Management Nursing Information System) provides on-line documentation of patient care orders. These orders, generated by the nurse or the physician, prescribe direct patient care and do not include interdepartmental orders such as laboratory, radiology, or pharmacy. The order charting functions support charting efficiency by defaulting previous responses so that the user enters only updates to earlier findings or new data. Available in tables maintained by NIS staff, charting responses provide decision support by suggesting valid results for each order. Using point-of-care devices, nursing staff chart patient data that are immediately available for review by all authorized members of the health care team. These data are printed automatically on computer-generated chart forms every twenty-four hours, but may be printed also on demand. Additionally, the patient data report, containing patient data entered on-line in the sixteen or twenty-four hours immediately preceding the print request, provides a summary that is useful for nurses' report and physicians' rounds.

Documentation↗
PubMed1995

[Achieving uniformity of documentation in child and adolescent health care. Child and adolescent medicine electronic data processing scope convention as the basis of GBE, Dresden Public Health Service Congress, May 1995].

A uniform medical documentation system for school health care in the FRG does not seem to be realistic. On the contrary, a system based on singular modules could be adapted to the different local or regional requirements. This solution depends on two agreements, first of all the formal compatibility of the database, and secondly a compulsory basic panel to guarantee uniform youth health reporting.

Adolescent↗
PubMed1996

[Admission documentation of multiple trauma patients using the Zurich Trauma Protocol--initial experiences].

A new protocol to document multiply injured patients in presented. It consists of 23 pages and is indexed on the right side. The pages are structured according to the Abbreviated Injury Scale (AIS): head/neck, face, thorax, abdomen, extremities/pelvis and integument. Different checklists on the right side of each page help to enter data efficiently; schemes and templates on the left side provide further support to visualize and classify the injuries. Summaries for diagnosis, therapies and for further investigations provide a standardized overview of the patient. The experiences of 22 residents were analyzed after one year of the protocol use. The trauma protocol was shown to be easy to learn, it was well accepted, and it increased the exchange of information between the emergency room and the intensive care unit. However, some residents considered this data entry to more laborious compared with the traditional medical record system. The trauma protocol was designed for prospective data acquisition of intensive care patients; it provides also a uniform structure for retrospective analysis and is therefore a helpful tool to increase quality control and quality assurance.

Abbreviated Injury Scale↗
PubMed1996

[A documentation procedure for community social psychiatry services--a pilot project in Bielefeld and Minden].

The status of health reporting (on community levels) has improved considerably during recent years. It is being increasingly used as an instrument for planning, controlling and evaluating political processes. In addition to individual studies the statistics within the departments of the health authorities are an important factor for meaningful health reporting on a local level. The IDIS (from Jan. 1st, 1995 LOGD) and the social psychiatric services on the Minden-Lübbecke district and the city of Bielefeld have developed a programme for automation-aided management of the statistics for social psychiatric services on a local level. Details on the personal situation and illnesses of the clients as well as on the activities of the services staff are recorded and analysed. Based on the WHO programme EPI-info 6.01 the documentation programme SPD-STAT was developed. This programme is menudriven and, in addition to the functions for the statistical data input and retrieval of fixed table sets, also offers the possibility of processing data with the full functionality of the ANALYSIS-module of EPI-Info. Thus interactive ad-hoc evaluations for current questions are made possible. Using SPD-STAT in as many local regions in NRW as possible may be a big step forward for health reporting on local levels as well as for health reporting on a state level.

Community Health Planning↗
PubMed1996

The documentation of thoracic endoscopy.

Thoracic endoscopy encompasses bronchoscopy, esophagoscopy, laryngoscopy, mediastinoscopy, and thoracoscopy (pleuroscopy). In this article, the role of documentation as it applies to bronchoscopy is discussed. However, the discussion is generally applicable to other thoracic endoscopy procedures.

Bronchoscopy↗
PubMed1996

Document management and scanning in the physician's office.

A popular PC magazine recently conducted a survey asking readers whether a paperless office or Santa Claus was more believable. Santa Claus won. Health care professionals would make that same choice. They come from an educational process that teaches, if it is not on paper, it never happened. However, the necessity for fast and easy access to medical documents, particularly in managed care networks, is causing the paperless office to rush forward at breakneck speed.

CD-ROM↗
PubMed1997

Assessing research productivity in an oncology research institute: the role of the documentation center.

An evaluation method used to assess the quality of research productivity and to provide priorities for budget allocation purposes is presented. This method, developed by a working group of the National Institute for Research on Cancer (IST), Genoa, Italy, is based on the partitioning of categories of the Science Citation Index and Journal Citation Reports (SCI-JCR) into deciles, which normalizes journal impact factors in order to gauge the quality of the productivity. A second parameter related to the number of staff of each institute department co-authoring a given paper has been introduced in order to guide departmental budget allocations. The information scientists of the IST Documentation Center who participated in the working group played a pivotal role in developing the computerized database of publications, providing and analyzing data, supplying and evaluating literature on the topic, and placing international bibliographic databases at the working group's disposal.

Documentation↗
PubMedDate not supplied

Documentation of the surgical procedure: a tool for quality assessment for breast conservative treatment.

In literature a lot of different approaches for breast conservation surgery have been recommended. Until now little prospective research has been done to identify the role of these variations on outcome. Within a group of surgeons participating in the same clinical trials, which give a number of specific directions, already a lot of variations in techniques are detected. This pinpoints two questions: firstly, what differences could be detected in non specialised general practices and secondly, which of those variations are important to be standardised. The documentation of the predetermined important technical factors and the development of clear guidelines for surgery are essential to implement a process of quality audit. This will probably be the best stimulus to raise treatment quality in breast cancer patients.

Axilla↗
PubMed1997

Simple guidelines for experimental reports, documentation and storage of data. A new initiative to further research integrity.

Since 1992, the Danish Medical Research Council has taken several initiatives to oppose scientific misconduct. One preventive measure has been the development of concise guidelines for the presentation of experimental reports and data documentation. After revisions and accept by the major user institutions, these guidelines have been well-received by a large number of research units and are made available to all Ph.D. students and their supervisors. We here describe the motives for the choice of guidelines and how they are adapted to the requirements of ongoing medical research in Denmark.

Clinical Medicine↗
PubMed1997

[Video stereophotography of the optic papilla. A practice-oriented documentation].

Video documentation of the posterior pole using a camera installed in the ocular part of a slitlamp provides visualization of the optic disc from two different angles by changing the ocular part with the camera from the right to the left. Using the appropriate video printer program (split 4) two pictures of the right optic disc are stored on the upper half, one shooting from the right the other from the left. The lower half of the print is reserved for the left optic disc. Thus stereoscopic perception of the optic discs can be achieved. By this means a simple procedure has been provided for improved follow up of glaucoma patients.

Documentation↗