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At least 37 records · Page 2Linked to original sources

PubMed2001

Standardized evaluation and documentation of findings in patients with craniosynostosis.

Surgical correction of craniosynostosis is usually performed according to standard procedures. However, a standard for clinical examination and report of findings for patients with craniosynostosis does not exist as yet. To compare findings from different hospitals, a documentation system was developed by a national craniosynostosis group. This system comprises a two-page document, clinical photographs, radiographs, CT scans, anthropometric measurements and molecular genetic findings. Data from craniosynostosis patients collected from participating hospitals are stored in a database, which facilitates online access.The documentation system was developed in cooperation with the group during 3 years since 1996. It was evaluated as being practicable and reliable and enables a comparability of findings reported in different hospitals. Molecular genetic analysis was found to support the investigation of patients with craniosynostosis and should therefore be integrated in the clinical evaluation. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.

Journal Article↗

PubMedDate not supplied

Improving physician documentation through a clinical documentation management program.

Improving physician documentation ensures that the patient's clinical course is clearly recorded. North Carolina Baptist Hospital implemented interventions addressing physician documentation to ensure the assignment of the most appropriate diagnosis-related group (DRG) when it launched the Clinical Documentation Management Program (CDMP). Collaboration between registered nurses trained as clinical documentation consultants (CDC) and certified coding specialists as well as ongoing physician education has resulted in more accurate and complete documentation in the medical record.

Concurrent Review↗

PubMedDate not supplied

[Rheumatism documentation--a uniform, modular documentation system for therapeutic studies in rheumatic diseases].

Being progressive and also involving variations in the severity of symptoms, chronic rheumatic diseases present difficulties with respect to documentation. Since dramatic changes in the course of disease are rare, early detection of very slight changes is essential to successful antirheumatic therapy. Practical means of documentation are necessary if an overview of the various clinical findings and subjectively reported symptoms is to be maintained over a period of many years. This is especially true in the case of therapeutic studies. The documentation form should enable the recording of suitably grouped data on the various rheumatic diseases and modes of therapy. With governmental support (BMFT project MT 0289), a uniform documentation form, "Dokumentation Rheuma", was set up and tested at 14 hospitals for rheumatic diseases. The modular form chosen and the definition of items were well received by the clinicians. After several modifications, a modularly structured documentation system is now available, elements of which can be expanded according to the needs of the individual therapeutic study. The form can both constitute a part of the patient history and act as a link between different but parallel-running studies, thus making it unnecessary to record the same information twice for different purposes. At the same time, the data base can be used to answer scientific and epidemiological questions independent of the study in progress.

Computers↗

PubMed2007

[Electronic documentation of injuries of the hand with a semantic network: effective and efficient methods for the documentation of clinical and administrative processes].

BACKGROUND: An efficient medical documentation is mandatory for a trauma-oriented department in the DRG environment. Besides the continuously increasing clinical/administrative demands, the additional documentation for quality assurance, clinical studies, and research requires additional efforts. Standard solutions are only partially effective. Especially in hand surgery there is a high demand for sophisticated clinical documentation, represented by a wide variety of classifications in diagnosis and therapy. The standard documentation tools lack accuracy. The development of a software tool that defines administrative/business processes and simultaneously generates clinical and administrative information was the goal of this project. METHODS AND RESULTS: With a standard medical terminology, an innovative semantic network, and a completely new graphical user interface, it was possible to develop and introduce a software program specifically adjusted for hand surgery. This program facilitated for the first time a single-stage acquisition of clinically relevant scientific data and the simultaneous generation of DRG, quality assurance, and administrative data relevant for the hospital's revenues. CONCLUSIONS: The newly developed software tool is a step forward into a new dimension of medical software, obviating the need for multi/documentation and significantly improving the quality of clinically relevant medical data.

Computer Graphics↗

PubMedDate not supplied

Is your document control out of control? Complying with document control regulations.

Clinical laboratories, faced with new or changing regulations and shortages in trained laboratory staff, may find it difficult to comply with guidelines related to document control, upkeep of standard operating procedure manuals, and documentation of quality programs or competency reviews. Now, more than ever, it is critical to keep documents, procedures, and training material organized and accessible to busy laboratory staff and inspectors. The key may be the ability to use existing software programs available to industry for similar compliance issues. The laboratory's ability to change and update quickly with limited staffing may depend on electronic solutions to the complexities of document control. Several software programs have merit and can be integrated into a clinical laboratory.

Arizona↗

PubMed1992

[Development and organization of a knowledge-based documentation system for ophthalmologic video documentation].

We introduce a system for documentation of ophthalmological video tapes. This system can be implemented without regarding the German data security law (Bundesdatenschutzgesetz), because the documentation of the patient identification and the video tape identification number is done manually and separated from the EDP-supported documentation of the video tape identification number and the contents of the tape. But the use of a controlled vocabulary framework for diagnosis and surgery can be considered as the main advantage of this system. This enables a complete and fast retrieval to all records containing the terms searched for. Our system provides additional space for non-standardized text-documentation, e.g. comments etc... The implemented search-editor allows a fast retrieval to all records by input of strings, which can be connected by boolean expressions.

Computer Security↗

PubMed1997

Nursing process documentation--effects on workload and quality when using a computer program and a key word model for nursing documentation.

In 1993 the federation of County Councils commissioned Spri to carry out a broadly based study aimed at investigating individualised patient care as described in the notes kept at various care units using computers to support documentation of the nursing process. The wards involved in the study represented various disciplines such as surgery, obstetrics, internal medicine, geriatrics and psychiatry. During the study period certain measures designed to improve the documentation were implemented i.e. a special computer program and structured nursing documentation following the VIPS-model. Interviews with staff at the units confirm that the introduction of computers, in combination with the structure of the VIPS-model and training in nursing documentation, has made changes possible to working procedures and brought greater goal orientation to the activity of care. The overall examination of the nursing entries in the patients' notes showed that the language has improved. The entries were to a greater extent expressed clearly and distinctly.

Computer User Training↗

PubMed1999

HL7 document patient record architecture: an XML document architecture based on a shared information model.

The HL7 SGML/XML Special Interest Group is developing the HL7 Document Patient Record Architecture. This draft proposal strives to create a common data architecture for the interoperability of healthcare documents. Key components are that it is under the umbrella of HL7 standards, it is specified in Extensible Markup Language, the semantics are drawn from the HL7 Reference Information Model, and the document specifications form an architecture that, in aggregate, define the semantics and structural constraints necessary for the exchange of clinical documents. The proposal is a work in progress and has not yet been submitted to HL7's formal balloting process.

Humans↗

PubMed2005

Falls documentation in nursing homes: agreement between the minimum data set and chart abstractions of medical and nursing documentation.

OBJECTIVES: To assess the agreement between falls as recorded in the Minimum Data Set (MDS) and fall events abstracted from chart documentation of elderly nursing home (NH) residents. DESIGN: Secondary analysis of data from a longitudinal panel study. SETTING: Fifty-six randomly selected NHs in Maryland stratified by facility size and geographic region. PARTICIPANTS: Four hundred sixty-two NH residents, aged 65 and older, in NHs for 1 year. MEASUREMENTS: Falls were abstracted from resident charts and compared with MDS fall variables. Fall events data obtained from other sources of chart documentation were matched for the corresponding periods of 30 and 180 days before the 1-year MDS assessment date. RESULTS: For a 30-day period, concordance between the MDS and chart abstractions of falls occurred in 65% of cases, with a kappa coefficient of 0.29 (P<.001), indicating fair agreement. Concordance occurred between the sources for 75% of cases for a 180-day period, with a kappa of 0.50 (P<.001), indicating moderate agreement. During the 180-day period, chart abstractions showed that 49% of the sample fell, whereas the MDS revealed that only 28% fell. An analysis of residents whose falls the MDS missed indicated that these residents had significantly more activity of daily living impairment and significantly less unsteady gait and cane/walker use. CONCLUSION: The MDS underreported falls. Nurses completing MDS assessments must carefully review residents' medical records for falls documentation. Future studies should use caution when employing MDS data as the only indicator of falls.

Accidental Falls↗

PubMed2000

Comparison of event rates and survival in patients with unexplained syncope without documented ventricular tachyarrhythmias versus patients with documented sustained ventricular tachyarrhythmias both treated with implantable cardioverter-defibrillators.

Patients with unexplained syncope and inducible ventricular tachyarrhythmias during electrophysiologic testing have an increased cardiac mortality rate. We compared event rates and survival of 178 patients with unexplained syncope and no documented ventricular arrhythmias (syncope group) versus 568 patients with documented sustained ventricular tachycardia (VT or fibrillation (VF) (VT/VF group) treated, as part of a lead (Ventritex TVL) investigation, with similar implantable cardioverter-defibrillators (ICDs) capable of extensive data storage. The 2 groups shared similar clinical characteristics. The mean follow-up was 11 months for the syncope group and 14 months for the VT/VF group. The mean time from device implantation to first appropriate therapy was similar in the 2 groups (109 +/- 140 vs 93 +/- 131 days, p = 0.40). Actuarial probability of appropriate ICD therapy was 49% and 55% at 1 and 2 years, respectively, in syncope group and 49% and 58% in VT/VF group (p = 0.57). Recurrent syncope was associated with ventricular tachyarrhythmias in 85% and 92% of the syncope group and VT/VF group, respectively (p = 0.54). At 2 years, actuarial survival was 91% in the syncope group and 93% in VT/VF group (p = 0.85). We conclude that patients treated with ICD with unexplained syncope and induced VT/VF have an equally high incidence of appropriate ICD therapy and low mortality compared with similar patients with documented VT/VF. These findings, plus the high association between recurrent syncope and ventricular arrhythmias, indicate that VT/VF are likely etiologies in selected patients with unexplained syncope and support ICD therapy in such cases.

Aged↗

PubMed2000

[Quality assurance and documentation for community mental health services cooperative (GPV). A standardized procedure for regional health care documentation and planning].

This paper describes a standardized assessment-procedure for the so-called "Gemeindepsychiatrische Verbünde" in Germany (GPV-Documentation), which are regional combines of community-based mental health care services. It is the first procedure in Germany which puts data on psychiatric care offers, needs for care and service utilization of all sectors and services in community-based mental health care into standardized measures, thus making offers and care of these services comparable. The procedure can be applied to the daily routine of catchment areas. From a methodical point of view the GPV-Documentation keeps a functional approach to community-based mental health care, but additionally it enables services to describe their specific contribution to regional care separately from others. Annual follow-ups make the GPV-Documentation an ideal tool for planning purposes, care management and quality assurance. Cross-regional comparisons of standards of care are possible. The implementation will also enhance the quality of governmental health reports on the care of chronically mentally ill in Germany remarkably.

Community Mental Health Services↗

PubMed2004

Inter-document coreference resolution of abnormal findings in radiology documents.

In the clinical environment, it is often necessary to track the progression of a condition or various pertinent findings over time. Establishing automatic mechanisms for tracking pertinent findings can aid in the management of a condition as well as provide feedback for treatment outcomes assessment. This work focuses on the challenge of correlating observation of pertinent findings, specifically lung masses, across documents from serial computed tomography examinations for lung cancer patients. A probabilistic model is presented to characterize the likeliness of two observed findings from different documents referring to the same entity. A greedy algorithm is also presented that utilizes the probabilistic model to establish coreference links between findings. Results from a preliminary evaluation of this methodology show a precision of 72% and a recall of 63% for the described inter-document coreference resolution task.

Algorithms↗

PubMed2005

Document ontology: supporting narrative documents in electronic health records.

Electronic health records (EHRs) are beginning to manage an increasing volume of narrative data, such as clinical notes pertaining to admission, patient progress, shift change, follow-up, consultation, procedures, etc. These documents fall into a wide variety of classes, based on who is writing them, for what purpose, and in which location, suggesting the need for a document ontology (DO) to model our knowledge of health care documents and their properties. This paper focuses on one aspect of the Health Level 7 (HL7)/ Logical Observation Identifiers, Names, and Codes (LOINC) DO, the Subject Matter Domain (SMD). We created a new polyhierarchical structure for the SMD that combines the current value lists from the LOINC database with another value list from the American Board of Medical Specialties (ABMS). We refined and evaluated the new structure through expert review of the ontology, a survey of medical specialty boards, and specification of SMDs for a corpus of clinical notes.

Attitude of Health Personnel↗

PubMed2000

[A standardized documentation structure for data documentation in echocardiography. Work Team on Standards and LV Function of the Work Group on Cardiovascular Ultrasound of the German Society of Cardiology, Heart and Circulation Research].

Presently, there are no well-defined standards for documentation of echocardiographic studies. Nevertheless, standards are essential to provide comparability of data and to realize electronic communication, both essential for quality management in echocardiography. Therefore, the working group "Standards and LV function" of the German Society of Cardiology developed a consensus for documentation of echocardiographic studies. In the present paper this consensus is presented and illustrated by typical clinical examples. Additionally, a prototype of a user-oriented software based on this data set is presented. The complete data set for transesophageal and transthoracic echocardiography and the software prototype can be downloaded at http:@echo.ma.uni-heidelberg.de.

Aortic Valve Stenosis↗

PubMed1993

Comparison of motor vehicle damage documentation in emergency medical services run reports compared with photographic documentation.

STUDY OBJECTIVE: To determine whether emergency medical services (EMS) run reports adequately document vehicle damage when compared with vehicle photographs by using a traffic accident scoring system. DESIGN: A prospective study consisting of three phases: photographing motor vehicle collisions and collecting their respective EMS run reports, traffic accident damage score development, and comparison of photographs to the run reports by emergency medical technicians using the traffic accident damage score. SETTING: Data were collected in North Carolina and Ohio from motor vehicle crashes to which nine different EMS squads responded during a three-year period. TYPE OF PARTICIPANTS: EMS squads ranged from basic to paramedic levels of training. MEASUREMENTS AND MAIN RESULTS: Three emergency medical technicians were unable to determine the area of vehicle damage in 48% and the severity of damage in 61% of the EMS run reports. In contrast, there were no instances in which all three emergency medical technicians were unable to determine both area and severity of damage from the photographs. CONCLUSION: Most EMS run reports do not document vehicle damage adequately.

Accidents, Traffic↗

PubMed2006

Every document and picture tells a story: using internal corporate document reviews, semiotics, and content analysis to assess tobacco advertising.

In this article we present communication theory as a conceptual framework for conducting documents research on tobacco advertising strategies, and we discuss two methods for analysing advertisements: semiotics and content analysis. We provide concrete examples of how we have used tobacco industry documents archives and tobacco advertisement collections iteratively in our research to yield a synergistic analysis of these two complementary data sources. Tobacco promotion researchers should consider adopting these theoretical and methodological approaches.

Advertising↗

PubMed1999

[30 years of computer-based clinical documentation at the Heidelberg University Orthopedic Clinic. From basic documentation to medical controlling].

An overview of the 30 years history and development of documentation and information systems in the Orthopedic University Hospital Heidelberg is presented. Since the foundation in 1967 four developmental phases can be described: first initiatives of medical doctors, establishment of a basic documentation system for scientific purposes, strategic information system planning and realisation of information systems with the possibility of controlling in medical areas and thereby steering of the services. Planning and realisation were accomplished within the framework of the masterplans and concepts of the university clinics of the state of Baden-Württemberg.

Academic Medical Centers↗

PubMed1986

[Clear text-oriented documentation in hand surgery--integrated in the medical routine documentation service].

For reasons of contents and economy, the construction of medical documentation should be integrated into the secretary's routine work. An efficient and inexpensive microcomputer is able to facilitate and accelerate the typing work of a hand surgical section by the use of a modern data processing system. At the same time important data can be stored for documentation without being coded and with hardly any additional effort. The dates can be analysed according to different criteria (e.g. statistics of diagnosis/therapy, the recall of data of patients with certain diagnosis, yearly statistics and so on). Knowledge of data processing is not necessary.

Computers↗