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PubMed1977

Problem oriented medical record: a predetermined problem list for spinal cord injury.

The Problem Oriented Medical Record is ideally suited to the documentation and management of patients with spinal cord injury, with their involvement of multiple organ systems and need for long term follow-up. The classic format described by Weed has been modified by use of a predetermined problem list, subdividing spinal cord injury into eight problems. We find this method to be of value in organizing the records and managing patients, from the acute phase to the follow-up phase, and additionally in organizing the records of long term patients when seen in follow-up. The problems listed are: 1--neurologic injury; 2--spinal skeletal injury; 3--other injuries; 4--general medical conditions; 5--urologic; 6--gastrointestinal; 7--sexual function; 8--rehabilitation. As complications or other problems arise, they are added to this list. Presented are two case histories, one of a long term patient and the other of a patient with new acute spinal cord injury to illustrate the application of this method.

Adult↗
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↗
PubMed1975

[Our programmed headache medical record. Contribution to the systematic registration and processing of a larger amount of headache patients using the computer].

We present a detailed anterospective inventory on headache which has been developed systematically with several alterations in the course of the experience of several years. It offers the possibility of an almost complete collection of data which can be fed directly into a computer and it appears to be a valuable aid in the training of new co-workers. Some clinical results are discussed on the basis of the inventory.

Austria↗
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↗
PubMed1975

Problem-specific coding systems.

The data found in medical records, particularly in problem-oriented records, could yield very useful information for many aspects of the health care delivery system. Unless the tools and methods used in the analysis of health care data are very carefully designed, the potential value of this information cannot be fully realized. Coding is a critical step in the process of converting medical record data into useful information. This paper presents six criteria as design goals for a standard, comprehensive, coherent set of nomenclatures, classifications, taxonomies, and corresponding coding schemes for the analysis of medical and administrative record data. These goals are: compatibility with established routine operating procedure, health care problem specificity, hierarchical structure, economy through articulation of the components with one another and through the similarities in various aspects of health care delivery, and adaptability to change.

Classification↗
PubMed1977

Integration of pharmacy into the computerized problem-oriented medical information system (PROMIS)--a demonstration project.

The integration of pharmacy into the computerized problem-oriented medical information system (PROMIS) at the Medical Center Hospital of Vermont is discussed. Practioners who generate and retrieve information communicate directly with the computer without intermediary personnel. Touch-screen cathode-ray tube terminals are used for data input. Under PROMIS, the pharmacist has two new resources which better integrate his services into total patient care: (1) the ability to directly access online patient data in the pharmacy, and (2) the ability to directly couple online current drug information to a specific patient's computerized medical record in the pharmacy. The PROMIS solutions to pharmacy problems in drug ordering, drug distribution and drug therapy audit are discussed; In a demonstration project on a 20-bed unit, PROMIS made the medical record readily available to all health care providers, reduced reliance on memory, preserved the logic of medical action, and provided feedback loops for corrective action in everyday medical practice. Also discussed are user acceptance of the system, effect on pharmacy staffing, and implications for pharmacy.

Computers↗
PubMed1978

Functional status evaluation form: development and implications.

A medical audit revealed marked deficiency in the quality of functional evaluations in a rehabilitation hospital. Routine staff educational programs and an optional, simple functional evaluation form failed to correct this deficiency. The functional evaluations of the patients never reached 100% completion and the quality of the evaluations varied widely. As a result, a mandatory functional status form was devised for incorporation into the patients' charts. This form included past, present, and future goals in a problem-oriented design. Review of charts after six months of use showed that the form led to improved rates of functional status reporting, with all functional areas now documented in over 90% of charts. It is hoped that a comprehensive program including use of functional status form will be successful in improving patient care and physician education, and in facilitating a comprehensive medical audit.

Activities of Daily Living↗
PubMed1976

System-structured management of acutely ill surgical patients.

The management of surgical patients requiring intensive care is complicated by abnormalities in multiple body systems. An effective method of organizing data collection and treatment is essential. The widely applied "problem-oriented" approach is not entirely satisfactory in the context of surgical intensive care. An alternative method is presented in which management is structured by body systems. The function of each system is analyzed and a plan for each is defined. Data display is arranged by systems rather than problems and is compatible with modern computer technology. A surgical patient under treatment for pancreatitis is presented to illustrate this approach. Experience with 220 patients on a residency teaching service supports the impression that system-structured management is an effective method of managing the course of an acutely ill patient and should be widely applicable to such patients in any general surgical environment.

Acute Disease↗
PubMed1975

Problem-oriented surgical audit in the community hospital. A concept in evolution.

A system of surgical audit based on identification and solution of surgical problems is described. The system relies initially on universal review of patient records on a monthly basis by surgeons in the involved institution. Evolution of the system to one which the records of certain patients can be excluded from review by physicians is seen as practical, if careful definition of such records is maintained. Emphasis on the goal of meaningful quality of care assessment is critial. Utilizing this system, surgeons in Stamford, Connecticut, have found significant deficiencies in diagnostic, therapeutic, or both of these aspects of patient care in 5 per cent of records reviewed. Ninety-five per cent of patients were judged to have had no important inadequacies in their surgical care, based on evidence in their medical records. Attempts to evaluate surgeons' behavioral changes, when deficiencies in their patients' care have been demonstrated, are being pursued actively.

Connecticut↗