[Nursing record and nursing-related records - keypoints in the nursing records and the modern hospital system].
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Hospital Administration↗
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Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters.
Information in 51 tape-recorded physician-patient encounters was compared with information written in the patients' medical records. Diagnoses, chief complaints, scheduled appointments, non-drug therapy, and diagnostic studies were uniformly well-recorded. Medication names were well-recorded but dosages were not. Characteristics of care such as levels of function, probable cause of illness, reason for follow-up, and compliance were recorded poorly. Patients were more likely to known about and understand their diagnosis, and names, dosage, and intended function of their medications when this information was written in the record than when it was not. These findings indicate a relationship between the quality of medical records and the effectiveness of care.
Child↗
Studies on the reliability of vital and health records: I. Comparison of cause of death and hospital record diagnoses.
Based on computer linkage of death records and hospital discharge abstracts, underlying cause of death and discharge diagnoses are compared for 9,724 Vermont resident in-hospital deaths occurring between 1969 and 1975. The agreement between the diagnoses recorded in the two data systems provides a measure of the reproducibility of recording, abstracting, and coding practices. Using the first three digits of the International Classification of Diseases, the agreement between cause and closest medical record diagnosis was 72 per cent. Concordance declined by patient age and length of hospital stay and varied significantly by coded cause of death. A major source of variation was the hospital of death where agreement levels ranged between 45 and 84 per cent. The latter finding is regarded as a potential starting point for targeting investigation of sources of discrepancy and initiating efforts to improve diagnosis recording and coding in the two record systems. The value of both depends on continuing efforts to improve and maintain data quality.
Age Factors↗
Reading the medical record. I. Analysis of physicians' ways of reading the medical record.
Physicians were interviewed about their routines in everyday use of the medical record. From the interviews, we conclude that the medical record is a well functioning working instrument for the experienced physician. Using the medical record as a basis for decision making involves interpretation of format, layout and other textural features of the type-written data. Interpretation of these features provides effective guidance in the process of searching, reading and assessing the relevance of different items of information in the record. It seems that this is a skill which is an integrated part of diagnostic expertise. This skill plays an important role in decision making based on the large amount of information about a patient, which is exhibited to the reader in the medical record. This finding has implications for the design of user interfaces for reading computerized medical records.
Decision Support Techniques↗
Combining final impressions with maxillomandibular relation records in stabilized record bases.
The postinsertion problems of complete denture prostheses are closely related to accurate recording of maxillomandibular relationships. It is essential that these recordings be made with stable record bases; making the final impressions within the record bases prevents movement and tilting. Face-bow and centric relation records properly orient the casts in the articulator. A method to obtain all of these records in one dental appointments has been described.
Dental Articulators↗
An end-to-end computational framework for "Record-seq" transcriptional recording data.
MOTIVATION: Record-seq captures cumulative transcriptional activity over time in engineered Escherichia coli by integrating cellular RNA-derived spacer sequences into clustered regularly interspaced short palindromic repeats (CRISPR) arrays, which are read out by sequencing. Unlike the approximately uniform transcript sampling of RNA-seq, Record-seq records biological signal as spacers sampled by the CRISPR spacer acquisition machinery. Consequently, standard RNA-seq analysis strategies are not directly applicable, limiting sensitivity and interpretability. Our previous pipeline addressed these challenges only partially, retained inherited RNA-seq assumptions, and had limited algorithmic efficiency. RESULTS: Here, we present an end-to-end computational framework for Record-seq data. To address the primary computational bottleneck of spacer sequence extraction, we implemented a wavefront alignment approach for efficient quasi-local pattern matching, achieving an approximately 30-fold speedup. We introduce transcription unit-based feature counting as an alternative to gene-body quantification to better represent prokaryotic transcription and increase statistical power by capturing signal from untranslated regions, which are spacer acquisition hotspots. For downstream analyses, we incorporate multiple normalization strategies and a nonparametric differential expression testing framework designed for sparse datasets. Further, we analyze spacer acquisition patterns and train sequence-based neural models that predict acquisition propensity from genomic sequence and annotations, providing a framework for assessing whether acquisition rules generalize as Record-seq is extended to new microbial hosts. AVAILABILITY AND IMPLEMENTATION: The primary analysis workflow, the recoRdseq package, acquisition modeling repository, and relevant data are all linked at https://github.com/plattlab/Record-seq-Framework. Acquisition models and training data are on Zenodo at https://doi.org/10.5281/zenodo.18891434.
Escherichia coli↗
Gastro-oesophageal acid reflux. Method for 12-hour continuous recording of oesophageal pH with analysis of records.
Description of method for continuous recording of oesophageal pH and automatic, electronic analysis of records. Stability of apparatus has been tested over 12 hours in the laboratory with different buffer solutions and gastric secretions with and without bile, and on 36 patients with oesophageal disorders. Drift of apparatus max. 0.2 pH units. The analyser, dividing the pH range into arbitrary intervals, performs a rapid and reliable analysis of single examinations from variable criteria. The temporal distribution of pH values into the intervals is expressed in percentages of the total time of recording. Reliability of the analyser was tested by analysis of a simulated pH curve on which changes in amplitude corresponded to the most rapid changes seen in practice. Deviation below one per cent. Repeated analyses of the same records showed a coefficient of variation for the various analytical interval to be 10-0.01 per cent. The method allows recording of the number of reflux episodes, duration of each episode and total duration of pH within chosen limits.
Adult↗
A new tocograph with cassette recording system and separate servo graphic recorder.
In order to register contractional activity, especially in the case of high-risk pregnancies, a tocograph was develop by means of which the contractions are registered by a small cassette recorder, which the patient can carry by about with her. A separate graphic recorder is responsible for the playback and this recorder remains at the doctor's practice. The patient is able to register her contractions herself as the unit is so simple to use. The recording section weighs only 500 grams, including the specially developed pressure transducer with optical distance-meter. The tocograph is produced in series.
Female↗
Recording centric and eccentric occlusal disturbances with a new recording device.
A recording device termed a "Kleinrok Functiograph" was introduced to simultaneously document condylar- and tooth-guided mandibular movements on the same plate. The Functiograph instrument permitted objective monitoring of mandibular movement without tooth contact, with all tooth contacts, and allowed analysis of the correlation of these two recordings. After 10 years of conducting investigations on centric occlusion using the Functiograph instrument combined with clinical, radiographic, and electromyographic studies, it was possible to differentiate the horizontal Functiograph recordings of normal and disturbed centric occlusion at a clinically acceptable vertical dimension. Two types of centric occlusal disturbances were classified to accelerate diagnosis and standardize communication.
Centric Relation↗
Application of a tape recorder ZK-246 for four-channel recording of some physiological phenomena.
A method of simultaneous recording of our physiological phenomena on a magnetic tape was described. A block construction of a transducer enabling four-channel record on a two channel, stereophonic tape recorder has been presented.
Electronics, Medical↗
Manual record-keeping and statistical records for the operating room.
Surveys have shown that handwritten anesthesia and circulating records kept in hospital operating rooms may be inadequately maintained and analyzed. Online, fully automated data processing techniques have been applied to reduce the anesthesiologist's recordkeeping workload, but with limited receptivity. An off-line data processing system has been developed using handwritten records to provide both anesthesia and operating room utilization statistics. Evaluation of the system indicates that an online, semiautomated approach applied only to charting vital signs and recording utilization statistics is an appropriate one for future development.
Anesthesia↗
[Recording of ventricular pressure by conventional catheter manometer systems. I. Minimal requirements of blood pressure recording systems and estimation of frequency response characteristics].
Parallel recordings of pressure pulses by conventional catheter manometer systems and catheter tip manometer demonstrate severe errors in the peak velocity of pressure rise estimated by conventional systems. This fact is due to inadequate dynamic response characteristics of conventional systems in relation to the frequency content of pressure curves. During cardiac rest the error in dp/dt max is less than 10% if the frequency response of the recording system is uniform up to 10 Hz, the corresponding value under maximal cardiac stimulation is about 40 Hz. This is equal to the first 10 harmonics of heart rate. The examination of left and right ventricular pressure curves leads to similar results. The experimental determination of dynamic response characteristics of cathermanometer systems requires a test system producing suitable sinus or step functions, parallel high fidelity recording of pressure functions to be recommended. A simple test station is described. Examinations of temperature influence on catheter material and resulting changes in dynamic response characteristics were carried out. The incubation of catheters at the temperature of 37 degrees C is indispensable. A new diagram for simplifying the interpretation of results is described. Other publications are discussed in viewpoint of employed techniques and representation of results.
Blood Pressure Determination↗
An integrated medical record and data system for primary care. Part 8: the individual patient's medical record.
This is the last in a series of eight articles describing an integrated system of recording medical data as developed and used by the Family Medicine Program at the University of Rochester-Highland Hospital. Compatability of manual and automated systems has been described. The total system allows the practicing family physician to assess morbidity patterns within his/her practice more effectively, to record and monitor patient care, to perform audit, and to conduct research in primary care.
Humans↗
An integrated medical record and data system for primary care. Part 6: a decade of problem-oriented medical records: a reassessment.
The Problem-Oriented Record (POR) has had a profound effect upon the medical community. Since its introduction not quite ten years ago, POR has gained remarkable acceptance. A short review of the relatively brief history of POR is given and various facets of its use are outlined as guidelines for more critical reappraisal of its merits. The fact, however, that POR is currently taught in a majority of medical schools and used in ever increasing numbers of hospitals is highly indicative of eventual conversion of all medical recoreds to POR format.
Diagnosis↗
Reproducibility of the normalized electromyographic recordings of the masseter muscle by using the EMG recording during maximal clenching as a standard.
A method of normalizing the integrated EMG recordings from the masseter muscles is introduced. For each subject investigated the maximal clenching force is remarkably constant and reproducible. This makes it possible to normalize the integrated EMG recordings to the EMG activity at the maximal clenching force without having to measure this force at the beginning of every experiment. These normalized integrated EMG activities give a good quantitative impression of the static force exerted by the masseter muscle, and therefore can be compared quantitatively over several experiments. The realtionship between the normalized integrated EMG activities and the clenching force is linear up to approximately 80% of the maximal clenching force.
Bruxism↗
A new approach to ultrasound image recording using a video disc recorder.
A system utilizing a multi-image capacity video disc recorder rather than a photographic camera for the initial recording of ultrasound images id described, as well as the resulting benefits.
Television↗
Reading the medical record. II. Design of a human-computer interface for basic reading of computerized medical records.
A user interface for reading the medical record was designed and implemented on a workstation with a 19-inch colour screen. The text is presented on imitations of paper-pages. The pages are organized in bundles which are dynamically connected to scrollable index lists. The turning of pages on the screen is the fundamental concept of the interface. A page can be turned by a mouse-click or by a circular mouse-movement. Elaborated feedback is given to the user in order to provide effortless orientation and navigation. The interface supports the basic ways of use identified in our analyses of reading habits. It also enables human perceptual and cognitive skills to be used. It seems very easy to learn and efficient in use.
Cues↗
Analysis of medical records of workers and the role of their occupational doctor. Report 1. A study on some impacts of aging of workers according to their health records.
The new "Occupational Safety and Health Act" was established in October 1972. According to the Act, the employers with 50 and more employees were bound to make an occupational health doctor provide health care for the employees within the enterprises. Considering the national background mentioned above, the author examined the actual status of the medical and health care services in order to discuss the professional function of an occupational health doctor by reviewing the records concerning the workers' health at a certain paper factory managed by the National Government, under the Government Health Insurance scheme. The results were as follows: 1) Aging of the workers had an important impact on medical service and health care provided. 2) The medical service by the occupational doctor attached to the factory differed much from that by other medical institutions outside the factory in several points; particularly in days of receiving medical consultation, medical expenditure expressed in "point score," number of injections given and the frequency of laboratory examinations. 3) as a whole, the occupational health doctor was taking a role as "the first contact doctor" in primary medical care, as well as a health officer preventing disease and promoting health in the factory, whereas the medical institutions outside the factory were rather clinically oriented in treating ill-health.
Adolescent↗