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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.
Some form of documentation of laparoscopic findings is essential in the proper management of the patient. We have found a simple outline form with a schematic drawing of the pelvis to be invaluable in emphasizing the need for a systematic and thorough endoscopic examination and in providing an excellent method of recall. Photographic documentation is primarily of value to those physicians involved in research or educational programs. In addition, we have found it helpful to give the patients a printed description of the procedure beforehand, as well as written instructions concerning preoperative arrangements and postoperative care.
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STUDY OBJECTIVES: To determine if the use of programmed charts with complaint-specific entry criteria results in improved documentation of patient encounters and better clinical outcome. DESIGN: Prospective study. SETTING: Emergency department of an urban university hospital. TYPE OF PARTICIPANTS: Female patients presenting to the emergency department with gynecologic complaints of abdominal pain, bleeding, or vaginal discharge. INTERVENTIONS: Programmed and blank charts were provided randomly for physicians in the ED. MEASUREMENTS: Chart scores based on documentation criteria for patient history, physical examination, laboratory studies, diagnosis, and discharge instructions and patient outcome scores of 0% to 100% based on the persistence of their complaints at the time of the follow-up interview. MAIN RESULTS: Overall documentation of history, physical examination, and laboratory studies was more complete on programmed charts than on blank charts (81.1% vs 71%, P less than .0001). The patient history portion of the charts was found to benefit the most from the use of programmed charts (74.8% vs 60.1%, P less than .0001). Although programmed charts demonstrated better documentation, there was no statistically significant correlation with patient outcome parameters or with patient satisfaction with the quality of medical care. However, more patients whose physicians used programmed charts were satisfied with their physicians' explanations of their problem (chi 2 = 5.2, P less than .02). CONCLUSION: Programmed charts improve documentation by facilitation of the documentation process and allow more time for patient-physician interaction. Quality of documentation alone, however, is not a reliable indicator of patient outcome or of the quality of care received.
Types of system and methods of documentation in clinic or hospital must be directed towards the object of the documentation: indexing or search documentation, informative or data documentation. Furthermore, a careful selection of the facts to be documented must be established, because a "complete clinical documentation" is unrealistic. Subtle knowledge of the methods of translation of medical facts into code numbers (coding techniques) is inevitable. Examples show how a very comprehensive data collection can be achieved in a short time from the documentation of only a few facts. Currently acquired data must be fed immediately for evaluation. The fact is criticized that some research promoters, when giving financial assistance for the installation of a data bank, shy away from providing the means for computer evaluation. In this way, useless "electronic data cemeteries" are produced. Consequently the demand, not only for the installation of data banks, but also to provide for their evaluation is deduced.
Manual and computerized systems for documenting interventions by pharmacists at a large university teaching hospital are compared. The manual system allows patient data and pharmacist interventions to be quickly documented on written profiles. Completed forms are entered into a personal computer for analysis. The computerized system is a direct-entry version of the manual intervention log. Five screens allow pharmacists to enter information into a mainframe computer from any terminal. Data can be downloaded from the mainframe into a personal computer. During the first part of the study, nine pharmacists used the manual system for seven days. After a two-week pause, the same pharmacists used the computerized system for seven days. The systems were evaluated by using time-and-motion analysis and a questionnaire. Also, the number of interventions documented and the characteristics of each were compared. The mean +/- S.D. time required to document an intervention was significantly less with the computerized system (81.8 +/- 24.9 seconds) than with the manual system (100.7 +/- 37.3 seconds). Administrative time for analysis and report generation was also less with the computerized system. The pharmacists rated the computerized system more highly in terms of ease of use, accessibility, time efficiency, and acceptability. The number of interventions documented did not differ between the systems. A computerized system for documenting pharmacist interventions compared favorably with a manual system.
Women asylum seekers and refugees face persistent barriers to maternity care (antenatal, intrapartum and postnatal care) across high-income countries, yet the upstream governance shaping access remains under-examined. Although legally distinct, both groups share protection-seeking experiences and are addressed jointly in governance documents. This study examined and synthesised how international (macro), European regional (meso), and United Kingdom (UK, micro) governance documents frame and operationalise maternity service access. Sixty-four documents were analysed using the READ framework. Inductive analysis of macro and meso documents identified six access dimensions: universal coverage; cultural and linguistic adaptation; rights-based approaches; multi-agency collaboration; data, monitoring and accountability; and quality of care. These dimensions structured assessment of UK governance, with jurisdictions rated strong, moderate or weak. Alignment was fragmented: Wales, Scotland and Northern Ireland exempted asylum seekers from charging, whereas England retained charging provisions. Multi-agency collaboration was consistently articulated, yet none of the 35 UK government documents focused on maternity access for this population, and none required outcome monitoring disaggregated by asylum or refugee status. UK governance appears coordinated in form but fragmented in substance. UK-wide minimum standards and routine recording of these data, with safeguards against immigration-related use, could strengthen coherence and accountability and improve visibility of inequities.
Finding time to perform thorough documentation in a busy oncology outpatient setting is an increasingly difficult task. This article describes the development of a new documentation system designed for an oncology outpatient unit. The system consists of a set of documentation tools that are specific for the type of patient visit, an initial assessment form, and guidelines for using the forms. The system was developed to reduce the amount of nursing time spent on documentation and to improve the quality of the documentation. Evaluation of the system indicated that the forms decreased charting time by 50%. Suggestions for modifying and revising the tools are included. This system could be adapted for use in any ambulatory oncology setting.
As hospital length of stay has decreased and patient acuity has increased, the nurse is confronted daily with the challenge of managing time between patient care and documentation. Documentation of care has consistently been a time-consuming and frustrating part of nursing practice. The nursing shortage has only compounded this problem. St. Joseph's Hospital has creatively begun to facilitate documentation by developing a Nursing Automated Documentation System (NADS) in collaboration with CliniCom, Inc. of Boulder, Colorado. This article documents the development and implementation of the system.
This paper describes MetaIndex, an automatic indexing program that creates symbolic representations of documents for the purpose of document retrieval. MetaIndex uses a simple transition network parser to recognize a language that is derived from the set of main concepts in the Unified Medical Language System Metathesaurus (Meta-1). MetaIndex uses a hierarchy of medical concepts, also derived from Meta-1, to represent the content of documents. The goal of this approach is to improve document retrieval performance by better representation of documents. An evaluation method is described, and the performance of MetaIndex on the task of indexing the Slice of Life medical image collection is reported.
The primary purpose of apnea monitoring is to ensure adequate warning of certain life-threatening respiratory and cardiac events, often in infants monitored at home. However, parents often become frustrated by frequent alarms, and other may not use the monitor at all. Unfortunately, ECRI has received a number of incident reports in which infants have died while not connected to their monitors or where a failure to monitor was suspected. We believe that some of these deaths may have been prevented if monitoring had been used properly. The most important step that parents can take to achieve effective monitoring is to faithfully follow the directions of their doctor. In an effort to ensure parental compliance, documentation capability has been added to many of today's monitors. In addition, those involved in providing patient care, especially the prescribing physicians, durable medical equipment (DME) providers, report scorers, interpreting physicians, and other clinicians, should carefully review their monitoring programs and the available documentation monitoring systems to determine how they can best meet their patients' needs. Below, we discuss the factors to consider when contemplating documented apnea monitoring and when selecting a documented monitoring system. The documentation features discussed are those we considered to be distinguishing factors among the systems evaluated in this issue and affected how we rated and ranked these units.
This paper describes MetaIndex, an automatic indexing program that creates symbolic representations of documents for the purpose of document retrieval. MetaIndex uses a simple transition network parser to recognize a language that is derived from the set of main concepts in the Unified Medical Language System Metathesaurus (Meta-1). MetaIndex uses a hierarchy of medical concepts, also derived from Meta-1, to represent the content of documents. The goal of this approach is to improve document retrieval performance by better representation of documents. An evaluation method is described, and the performance of MetaIndex on the task of indexing the Slice of Life medical image collection is reported.
Presented is a program of recording all facts in the fate of a cancer patient relevant for therapy and prognosis in a manner suitable for EDP. Beside optimal medical treatment it is the substance of the documentation system to produce the complete pathogram of all registered cancer patients. From the day of establishment of the diagnosis and the begin of clinical treatment in the Evgl. Krankenhaus up to the following 5 years the cancer patient runs through a strongly termed and tumor specific follow-up. All informations and facts are registered in a codable medical record, a basic documentation for tumor patients, a follow-up and a final questionaire. In the so coded pathogram of the cancer patient we only use international binding classifications and coding systems. The pathogram is the result of a longer development and testing time in the surgical department of a smaller hospital. The presented principles of documentation include all basis necessary for the establishment of a clinical cancer registry and documentation follow-up.
Using our Perioperative Nursing Process form in addition to intraoperative and PACU flow sheets allows us to document the nursing process in a manner that satisfies the goals for documentation established by our committee. Because we place all forms in the patients' medical records, they are available for review by the JCAHO to prove that we comply with their standards and the standards of AORN and ANA. The nurses have been satisfied with the documentation system because it can be used efficiently and does not require redundant documentation as the patient transfers into each perioperative area.