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Results for “Medical Records, Problem-Oriented”

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At least 19 recordsLinked to original sources
PubMed1976

Communication as a method of medical audit.

Advances in the practice of medicine over the past forty years have rendered informal communication ineffective in setting and maintaining standards of clinical care. In the past five years, four methods in communication have been introduced in the department of surgery at Guy's Hospital: problem-oriented medical records, death-and-complications meetings, unit review meetings, and a clinical information service. It is suggested that these can achieve quality control.

Communication↗
PubMed1978

[Standard report forms in radiological diagnosis (author's transl)].

Standard report forms have been designed for excretion urography, gastro-intestinal examinations, cholecystography, myelography, trauma and surgical emergencies; the findings, which are printed on the form, are marked and the conclusion is then written by hand. If used for a limited number of examinations with recurring problems, these report forms results in a considerable reduction in effort and simplifies routine diagnosis.

Germany, West↗
PubMed1979

The evolution of the PSRO hospital review system.

Over the past several years, the PSRO hospital review system has evolved to such an extent as to merit re-examination of its objectives, accomplishments and potential, as well as the obstacles to success that still remain. The combination of review experience, political and funding pressures has reshaped the hospital review system. There is still controversy concerning the relative emphasis of the program on quality or costs, but there is no longer any question about the priority goal of the program for the remainder of this decade--to reduce the excessive use of hospital care and services that exists throughout the country. There is widespread and growing evidence of significant variation in hospital practice patterns from region to region and hospital to hospital. Elimination of much of the variation would benefit the quality of patient care and help to contain costs. Improvements in PSRO hospital review, particularly profile analysis and medical care evaluation studies, make possible the exposure of apparent local problems in hospital quality and utilization and the precise definitions of their causes. Many PSROs have made substantial progress in the application and refinement of these techniques. The current state of the art is described in detail. Still to be determined over the next several years is the extent to which PSROs will be able to succeed in correcting these problems and whether the support and cooperation PSROs need form sister agencies and the political process will be adequate.

Concurrent Review↗
PubMed1979

Auditing the process of care in a new geriatric unit.

To assess whether the objectives of a new Extended Care Unit were reflected in the care of the patients and in the outcome of that care, an audit of the patients' records was performed. The audit sample involved 101 geriatric patients who had been admitted to the Unit for rehabilitation therapy, and then discharged. The study included assessment of the records for compliance with individual audit criteria, examination of the records in terms of a composite audit score, and analysis of the relationship between these scores and three outcome indices. Although the audit did not show a significant correlation between recorded care processes and treatment outcomes, it did reveal the extent to which the Unit's goals were reflected in the care process.

Activities of Daily Living↗
PubMed1976

Functional status measurement and medical rehabilitation outcomes.

An on-stream method for describing patients' functional abilities is used to develop analyses of medical rehabilitation outcomes. Outcomes are the changes in status between admission, discharge and follow-up. Standardized observation and reporting make it possible to compare one date with another, one case with another or one agency or facility with another to determine program characteristics, effectiveness and efficiency.

Activities of Daily Living↗
PubMed1975

Upper-respiratory tract complaint protocol for physician-extenders.

A protocol for upper-respiratory tract complaints was administered to 226 patients in a walk-in clinic. The protocol, for use by a physician-extender in conjunction with a physician, specified the collection of data necessary for management. A decision-making algorithm separated the major causes of upper respiratory infection (URI) complaints and led to one of four plans: a physician referral, a culture only, antibiotic treatment, or symptomatic treatment only. Each patient was seen by a physician following the health assistant's interview. Of 226 patients, 96 (42 percent) would have been sent home by the protocol without seeing the physician. None of these had a complication of URI. Sixteen (seven percent) of the 226 had serious complications - all would have been referred to the physician. The protocol proved to be safe and efficient, acceptable to patients, and a reliable approach to physician-extender management of URI.

Anti-Bacterial Agents↗
PubMed1976

Protocol management of male genitourinary infections.

As part of a demonstration study, 567 male patients presenting to a "walk-in" clinic with common genitourinary complaints were interviewed by health assistants guided by a protocol. Independent examination of 19 patients by a health assistant and a physician formally demonstrated that the health assistants could collect the clinical data accurately. Forty-four patients were then randomly chosen to be examined, diagnosed and treated either by a health assistant guided by the protocol and supported by an available physician, or only by a physician. Using medical records and a follow-up interview, we assessed the thoroughness of the medical record, adequacy of diagnosis and treatment, symptom relief, patient satisfaction and patient education: the health assistant-protocol system proved as safe and effective as the MD-only system, and the health assistants were able to manage 68% of patients without involving the physician. The study suggests that briefly-trained health assistants may help save physician and nurse time, and that the development of protocols can help set standards for the medical management of defined problems while providing a mechanism for rapidly creating a complete medical record which can be easily audited for conformance with standards.

Adolescent↗