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At least 19 recordsLinked to original sources
PubMed2002

[Documentation of surgical performance--does more really help more? Comparison of the effects of maximum and limited documentation depth of clinical patient data on theoretical revenue volume of a surgical clinic after introduction of the DRG-based reimbursement system].

INTRODUCTION: The forthcoming introduction of a DRG-based account system in Germany aims at higher transparency and economic efficiency, particularly in the sector of in-patient health care. The availability of documentation of the highest quality, taking into account all potentially relevant diagnoses, appears to be the best method for achieving maximum revenue in individual surgical units. The aim of the study was to determine the relevance of various degrees of documentation depth on calculated DRG-based revenue. Furthermore, we evaluated whether improvements in the quality of documentation can be realized in current hospital organization. METHODS: In a prospective study, clinical data from 402 in-patients were collected and revenues were calculated based on the Australian-Refined DRG system. Various qualities of documentation were defined. In order to find the medical sectors most sensitive to "under-documentation", homogenous cases were classified into 23 treating groups, according to diagnosis. RESULTS: In 267 cases, maximum revenue was determined only by one main diagnosis, while better results could be achieved in 137 cases (34%) by extended documentation quality. Half of this gain could only be achieved by an independent medical documentation specialist. An upper limit of documentation intensity (number of diagnoses) could be defined. Maximum gain did not require maximum number of diagnoses. CONCLUSIONS: Documentation depth has an important influence on the calculated revenue of surgical therapy based on AR-DRG system. The quality and depth of the documentation is not, in itself, sufficient. In order to be really effective, it requires the highest degree of professionalism from hospital staff.

Cost-Benefit Analysis↗
PubMed1999

Document control and document management.

Most schemes for the accreditation (e.g. United Kingdom Accreditation Service) and certification (e.g. BS EN ISO 9002) of laboratories include a requirement to establish and maintain procedures for the management and control of documents generated internally. Such documents include policy statements, procedures, specifications, and some notices and memoranda. Organisations benefit from using agreed and approved information and from knowing that staff are using agreed and approved methods in their operating procedures. Document control systems are likely to become compulsory as accreditation schemes, such as Clinical Pathology Accreditation (CPA) for clinical microbiology laboratories, align with international standards. The Technical Services Division (TSD) in PHLS Headquarters has been developing a control system for various documents that it issues to the PHLS and control of documentation that forms the TSD quality system. The document control system has recently developed into a document management system that provides a mechanism for managing all documents generated or received by the division. TSD's approach is described here to provide laboratories and other organisations with ideas for how they could set up or develop their own document management system to improve accessibility to information.

Archives↗
PubMed2003

[Effects of a computer-assisted system for nursing care documentation on quality and quantity of nursing care documentation].

The University Hospital in Heidelberg has been gathering experience with the computer based nursing documentationsystem PIK since 1998. Its introduction on four pilotwards was systematically evaluated in an intervention study, gaining data to acceptance issues as well as to the quality of nursing documentation, as the nursing process is often not documented in an appropriate manner. Data to quantity and quality of nursing documentation before and after the intervention was gathered by means of a quality checklist, which was developed on the basis of an intensive literature review. To measure a difference in the quality of nursing documentation 20 documents from each of the four wards were assessed at the three assigned points of time by two nursing experts. The assessors stated a significant improvement in documentation quality due to the increase in formal completeness when documenting the nursing process. The content of the documentation as well as the individualization of the nursing care plan still need to be improved.

Attitude to Computers↗
PubMedDate not supplied

Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions.

OBJECTIVE: To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions. DESIGN: A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record. MEASUREMENTS: Completeness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropriateness of documented clinical decisions. RESULTS: The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records. CONCLUSIONS: Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes.

Chronic Disease↗
PubMed1997

[Definition and evaluation of a documentation standard for intensive care medicine: the ASDI(Working Group for Standardization of a documentation system for Intensive care medicine) pilot project].

OBJECTIVES: A comparison of data from different intensive care units (ICUs) needs standardized documentation. In this study the ASDI documentation standard for intensive care was tested in clinical practice. Goal of the study was to evaluate parameters and functionality required for a national, interdisciplinary documentation system for intensive care. DESIGN: 13 ICUs participated in a 4-week trial using the provided program for documentation of all admitted patients during the observation period. In addition, a questionnaire was distributed to the unit coordinators. RESULTS: 376 patients were documented in 1591 patient days. Valid SAPS II scores were found in only 29% of the discharged patients (39.1 +/- 15.5 points). Time needed for data entry exceeded preset limits (ten minutes per patient and day) in 38% of the cases. All participants affirmed the necessity of a documentation standard for intensive care, giving quality control and cost analysis as the most important reasons. CONCLUSION: The ASDI data set fitted existing needs very closely. Only 7 out of 122 parameters (5.7%) were found to be superfluous and thus removed. Measures to reduce documentation effort to the default limits were a) a new, date orientated concept for manual recording, b) rede-sign of the user interface with new, user friendly data entry possibilities, and c) the integration of statistical analysis and reports in the documentation system. The revised data set represents a broad-based consensus, which seems to be well-suited as foundation for the national quality assurance program.

Adolescent↗
PubMed2004

[Clinical patterns of community acquired pneumonia microbiologically documented compared to the not documented.]Prospective and comparative study between 1991 and 1997].

INTRODUCTION: The diagnostic of the pneumonia is the problems more important for its adequate treatment and best evolution. OBJECTIVES: To study in a prospective way the patron clinic de la NAC compared the documented with the not documented in a microbiological way. PATIENTS Y METHODS: We have studied patients with NAC hospitalized in the HUVA between January of 1991 and May of 1997. The diagnostical criterion of pneumonia and of the hospitable ingress were the classics accepted for this infections, was doing in all cases diagnostical studies not invasive. It was analyzed the clinical patron of the NAC microbiologically documented compare to with the not documented. In the same way, the documented was divided in typical and not typical according to the microorganisms aisled. Besides was realized an statistic study using tables of contingency and test Fisher. RESULTS: It was studied 409 patients with NAC, from which 161 (39.6%) had microbiological documentation, it was found 119 micro organism typical and 42 atypical. On the one hand, the female sex, EPOC, fever, tos and purulence esputum and hyperglucaemia, were associated significantly with the documented NAC. The presence of cardiopaty, seriously initial clinical situation, gastrointestinal disorders and previous infections and use of antibiotics, were associated with not documented. The age more than 65 years, presence of comorbility, purulence sputum, pleural pain, toghether with VSG>50 and lobar infiltrate, were associated significantly to typical pneumonia, while tabaquical habit and extrapulmonary sintoms (artromialgias) were with the atypical. CONCLUSIONS: The knowledge of the clinical patrons of the NAC are great impact in the diagnostic and treatment antibiotic adecuate.

Aged↗
PubMed2004

An evaluation of brainstem death documentation: the importance of full documentation.

BACKGROUND: With the introduction of the concept of brainstem death as acceptable proof that life has ended, rather than cessation of the beating heart, the process of determining brain death has to be rigorous to ensure maintenance of confidence in the definition. A recent study from South Thames in the UK revealed that only 44% of brainstem death documentation was complete at the time of referral to the transplant coordinator. The aim of our study was to see whether our documentation of brainstem death in paediatric practice complied with the UK Royal College's guidelines and to determine whether any changes are required to be instituted. METHODS: We studied retrospectively the case notes of children who underwent brainstem testing over a 3-year period (1994-1997) at two tertiary referral children's hospitals. The results of the audit were disseminated and a reaudit was performed over a 3-year period (1998-2001). RESULTS: A proforma was completed in 61% of cases and in only 54% of cases was the ideal standard of two tests by two doctors documented. Of the 26 sets of case notes studied, the cause of coma was not stated in 85% of cases and exclusion of other causes was stated in 54%. For the reaudit, 32 sets of case notes were studied and the proforma was completed in 100% of cases. In 91% of cases, the cause of coma was stated and in 94%, exclusion of other causes was documented. In 94% of cases two tests were performed by two doctors. CONCLUSIONS: Documentation of adherence to the Royal Colleges, guidelines on brainstem death testing improved significantly between the two study periods as a consequence of major changes in practice within the PICU. With the appointment of dedicated intensive care consultants, care became largely consultant intensivist led and emphasis was placed on the documentation and completion of a single validated brainstem death proforma. It is essential to improve and maintain the quality of brainstem death test documentation in order to ensure the integrity of the process.

Brain Death↗
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↗