[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↗
Reactivity in self-recording: obtrusiveness of recording procedure and peer comments.
Reactivity refers to behavior change that occurs during self-recording without specific programming of consequences. We analyzed the effects of obtrusiveness of recording procedure and peer comments on reactivity to self-recording. Three first-grade students in Experiment 1 completed math questions during a 5-min work period. When we gave the children recording devices and told them to try to complete more questions than the highest number they had previously completed, math performance increased, as did the number of verbalizations about it. Two children showed more reactivity when they used the more obtrusive recording device. Because the increase in math performance corresponded closely to increases in peer comments, we manipulated peer comments directly in Experiment 2. Four second-grade students completed a math task and an alphabet task. Three of the students showed increased math performance during periods when peer comments occurred compared to periods when peer comments did not occur. Although the data from the math task suggested that peer comments can enhance reactivity, we did not observe this relationship with the alphabet task. These results suggest that the conditions necessary to produce desirable results through self-recording are complex and contextually specific.
Auditory Perception↗
Short-term sleep EEG recordings after partial sleep deprivation as a routine procedure in order to uncover epileptic phenomena: an evaluation of 719 EEG recordings.
All night sleep deprivation prior to an EEG registration causes some inconvenience not only to the organization of the EEG department but presents a burden on the patients as well as their family members, and for these reasons is not suitable to be frequently employed as a routine procedure. As an alternative, we performed short-term sleep recordings in the early afternoon following a partial sleep deprivation of the patients during the preceding night. This method was well accepted by the patients and their family. Our only goal was to shorten the total time of night sleep using the following guideline: for very small children 22.00-06.00; for 4-14-year-old patients 24.00-06.00; and for patients older than that 01.00-06.00. 79.9%, out of 719 patients (573) who had been given the above instructions subsequently showed sleep patterns in their EEG. Additionally we had to administer an oral dose of promazine to only 67 patients. However, for the most part, patients showed only light sleep stages: 114 patients only reached sleep stage 1; 323 patients sleep stage 2; 88 patients sleep stage 3; and 48 patients sleep stage 4. As expected, REM sleep was never recorded. Nonetheless, in 32 out of 146 patients who were tired but unable to fall asleep, epileptic patterns could be provoked. In 636 patients, the EEG-recording after sleep reduction was ordered because of a suspected seizure disorder; in the remaining patients it was initiated solely because of sharp components in the routine-EEG. In 341 (53.6%) of the patients with suspected epilepsy, electroencephalographic activity indicative of a seizure disorder was activated. Such epileptic patterns were recorded almost exclusively in stages of waking, 1 and 2. Only in one out of the 124 patients who reached sleep stages 3 and 4 epileptic patterns were not seen until deep sleep was entered. We observed 2/s, 3/s and 6/s spike-and-wave complexes, sharp waves, spikes, polyspikes, groups containing remarkably sharp components and so called sharp vertex grapho-elements. Patients with suspected seizure disorders frequently show grapho-elements which can be interpreted as the expression of a disposition for epilepsy. These sharp vertex elements were evident in 54 out of 719 short term sleep recordings, more often in children than in adults. 49 times they coincided with typical epileptic discharges such as sharp waves, spikes or spike-and-waves in the same recording.
Adolescent↗
A simple electronic device for time-lapse recording of neural and other cell movements using a home video cassette recorder.
This article describes a simple electronic unit to obtain time-lapse recordings with the use of a common remote-controlled home video cassette recorder, for example a VHS recorder. The electronic unit is a timer to be connected to the remote-control unit. The video cassette recorder itself remains unchanged. Replay of the recorded images speeds up the original process by a factor of 2-100 x or more. This technique has been applied in video micrographic studies of (1) the development of dorsal root ganglion (DRG) cells in culture, including growth cone and Schwann cell movements, and (2) tumor cell killing by natural killer (NK) cells.
Animals↗
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 computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.
Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.
Humans↗
An algorithm for matching anonymous hospital discharge records used in occupational disease surveillance: anonymous record matching algorithm.
The expense of collecting primary data, coupled with limited authority to mandate reporting, requires alternative methods of implementing an occupational disease registry in Illinois. One alternative data source for surveillance of some occupational diseases is hospital discharge records. Because these records lack personal identifiers, it has been impossible historically to match records belonging to the same individual and obtain reliable case estimates. To circumvent this difficulty, an algorithm has been developed to match anonymous hospital discharge records collected from all Illinois hospitals. The algorithm was based on the assumption that specific combinations of occupational disease code, sex, zip code, and date of birth would identify an individual to whom multiple hospitalizations belong. Matching with the algorithm reduced the 1986 case estimates from 597 to 499 for all cases of coal workers' pneumoconiosis, asbestosis, and silicosis.
Algorithms↗
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↗
Holter monitor recording for the detection of myocardial ischemia: validation of a new recorder and chest lead positions.
OBJECTIVE: To validate the Reynolds Tracker II Holter system using newly described lead positions during both upright treadmill exercise and in the recumbent position following exercise. The specific lead positions HL1 and HL2 were chosen to detect anterior and postero-inferior myocardial ischemia, respectively, without interfering with the surgical field in the hypothetical situation of open-heart surgery. Similar lead positions have previously been used to monitor myocardial ischemia during induction of anesthesia, but have never been validated by comparison with 12-lead modified electrocardiogram (ECG) recording. METHODS: To validate the authors' 'chosen' Holter lead positions (HL1 and HL2), both at the fifth intercostal space just lateral to the midclavicular line and on the back, 1.5 cm to the left of the vertebral column, respectively) 49 candidates for routine treadmill exercise testing underwent a simultaneous Holter monitor recording using the described lead positions. DATA ANALYSIS: The Holter ECG recordings were separately analyzed by two physicians unaware of patients' identity. RESULTS: Using the modified 12-lead ECG as the 'gold standard', the sensitivity of Holter for detecting ischemia (defined as 0.1 mV or ST depression lasting at least 60 s) was 77 and 83%, and its specificity was 100 and 92%, respectively, for observers 1 and 2. Most episodes of myocardial ischemia were detected by the modified lead V5 for the 12-lead ECG and by HL1 for the Holter recording. Using the Holter Tracker II system and the chosen lead positions, it was possible to detect successfully most episodes of exercise-induced myocardial ischemia. CONCLUSION: Holter monitoring might be useful in detecting perioperative myocardial ischemia.
Coronary Disease↗
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↗