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International Journal of Clinical... Oct 2017Medications are perceived as health risk factors, because they might cause damage if used improperly. In this context, an adequate assessment of medication use history... (Review)
Review
Medications are perceived as health risk factors, because they might cause damage if used improperly. In this context, an adequate assessment of medication use history should be encouraged, especially in transitions of care to avoid unintended medication discrepancies (UMDs). In a case-controlled study, we investigated potential risk factors for UMDs at hospital admission and found that 150 (42%) of the 358 patients evaluated had one or more UMDs. We were surprised to find that there was no record of a patient and/or relative interview on previous use of medication in 117 medical charts of adult patients (44.8%). Similarly, in the medical charts of 52 (53.6%) paediatric patients, there was no record of parents and/or relatives interviews about prior use of medications. One hundred thirty-seven medical charts of adult patients (52.4%) and seventy-two medical charts of paediatric patients (74.2%) had no record about medication allergies and intolerances. In other words, there was a lack of basic documentation regarding the patient's medication use history. As patients move between settings in care, there is insufficient tracking of verbal and written information related to medication changes, which results in a progressive and cumulative loss of information, as evidenced by problems associated with clinical transfers and medication orders. Proper documentation of medication information during transfer is a key step in the procedure; hence, it should be rightly performed. It remains unclear whether interviews, and other investigations about medication use history have been performed but have not been recorded as health-care data. Therefore, it is crucial to the improvement of medication use safety that documentation of all drug-related information-even if not directly related to the actual event-become routine practice in health-care organizations, since 'what is not written does not exist'.
Topics: Documentation; Humans; Medical History Taking; Medication Errors; Medication Reconciliation; Transitional Care
PubMed: 28823070
DOI: 10.1007/s11096-017-0519-2 -
Nursing Ethics Mar 2022Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient...
BACKGROUND
Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored.
AIM
To explore ethical dilemmas in nurses' conversations about nursing documentation.
RESEARCH DESIGN, PARTICIPANTS AND CONTEXT
The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman.
ETHICAL CONSIDERATION
This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent.
FINDINGS
Ethical dilemmas were strongly present in nurses' conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients' autonomy and not causing harm, which was visible in nurses' navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses' balancing between documenting deviations and proof of nursing practice.
DISCUSSION
Ethical dilemmas in nursing documentation regarding respecting patients' autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records.
CONCLUSION
Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.
Topics: Decision Making; Documentation; Ethics, Nursing; Humans; Nursing Care; Qualitative Research
PubMed: 34866491
DOI: 10.1177/09697330211046654 -
The Clinical Teacher Feb 2018Medical students are often given non-standardised midpoint feedback and final evaluation on their history and physical examination documentation, despite this written... (Comparative Study)
Comparative Study
BACKGROUND
Medical students are often given non-standardised midpoint feedback and final evaluation on their history and physical examination documentation, despite this written communication being one of the most important aspects of patient care. This study aims to assess the effect of using a standardised feedback tool on overall student documentation performance.
METHODS
A standardised written evaluation form, called the history and physical examination write-up assessment (HAPA) form, was previously developed and published in The Clinical Teacher in 2011. This form evaluates the documentation of student communication, data collection and clinical reasoning, and was used to provide midpoint documentation feedback to one group of medical students, whereas a second group received non-standardised midpoint feedback on documentation. Final written history and physical examination documentation from both groups was then evaluated using the standardised tool to assess the effect of receiving more formalised midpoint documentation feedback using the HAPA form.
RESULTS
The group receiving standardised midpoint feedback using the HAPA form performed significantly better on the final evaluations of their documentation, especially when examining communication and data collection documentation. Performance in clinical reasoning documentation did not demonstrate a significant change between the two groups. Medical students are often given non-standardised midpoint feedback and final evaluation CONCLUSIONS: The use of a standardised evaluation tool, such as the HAPA form, may be associated with improved student documentation. This form provides educators with an effective tool to use when providing feedback and final evaluation of medical student documentation.
Topics: Documentation; Education, Medical, Undergraduate; Formative Feedback; Humans; Physical Examination; Quality Improvement; Students, Medical
PubMed: 28225204
DOI: 10.1111/tct.12625 -
Lakartidningen Oct 2023The scientific documentation of prehospital emergency care in Sweden is slowly expanding. The first thesis on the value of a mobile coronary care unit was defended in...
The scientific documentation of prehospital emergency care in Sweden is slowly expanding. The first thesis on the value of a mobile coronary care unit was defended in 1982. Since then, at least 106 theses have been defended at 15 educational institutes in Sweden. The theses can be divided into nine different themes, of which acute disease and prognostic factors (n = 30) is the most common, followed in order of frequency by caring, assessment and decision (n = 18), patient and next of kin perspective (n = 14), trauma (n = 1 1), competence, learning, and education (n = 10), care needs, cooperation, and prioritization (n = 10), disaster (n = 7), workers' health and environment (n = 3), and ethics and values (n = 3). The University of Gothenburg had the highest number of theses defended (n = 28), followed by the Karolinska Institute (n = 24) and the University of Umeå (n = 10). The theses were written by 64 nurses, 36 physicians, two public health specialists, one physiotherapist, one priest, one social worker, and one statistician.
Topics: Humans; Emergency Medical Services; Documentation; Sweden
PubMed: 37860864
DOI: No ID Found -
Journal of Medical Imaging and... Feb 2019The Royal Australian and New Zealand College of Radiologists (RANZCR) Radiology Written Report Guideline was first issued in 2011. A survey-based consultation of... (Review)
Review
The Royal Australian and New Zealand College of Radiologists (RANZCR) Radiology Written Report Guideline was first issued in 2011. A survey-based consultation of clinical radiology members of the college in 2015 found that the vast majority of 235 respondents supported all components of the guideline. Since the original guideline was developed, considerable new research has been published about radiology reporting, particularly regarding structured/template reports. In 2016/17 a RANZCR working group used the consultation results, stakeholder feedback and recent research to develop revised guidelines. This article outlines the consultation survey results and guideline revision process as well as some of the supporting evidence from the literature.
Topics: Australia; Diagnostic Imaging; Documentation; Humans; New Zealand; Radiology; Radiology Information Systems; Societies, Medical
PubMed: 30019848
DOI: 10.1111/1754-9485.12756 -
Australian Health Review : a... Jun 2021Objectives To assess whether adding clinical information and written discharge documentation variables improves prediction of paediatric 30-day same-hospital unplanned...
Using machine learning to predict paediatric 30-day unplanned hospital readmissions: a case-control retrospective analysis of medical records, including written discharge documentation.
Objectives To assess whether adding clinical information and written discharge documentation variables improves prediction of paediatric 30-day same-hospital unplanned readmission compared with predictions based on administrative information alone. Methods A retrospective matched case-control study audited the medical records of patients discharged from a tertiary paediatric hospital in Western Australia (WA) between January 2010 and December 2014. A random selection of 470 patients with unplanned readmissions (out of 3330) were matched to 470 patients without readmissions based on age, sex, and principal diagnosis at the index admission. Prediction utility of three groups of variables (administrative, administrative and clinical, and administrative, clinical and written discharge documentation) were assessed using standard logistic regression and machine learning. Results Inclusion of written discharge documentation variables significantly improved prediction of readmission compared with models that used only administrative and/or clinical variables in standard logistic regression analysis (χ2 17=29.4, P=0.03). Highest prediction accuracy was obtained using a gradient boosted tree model (C-statistic=0.654), followed closely by random forest and elastic net modelling approaches. Variables highlighted as important for prediction included patients' social history (legal custody or patient was under the care of the Department for Child Protection), languages spoken other than English, completeness of nursing admission and discharge planning documentation, and timing of issuing discharge summary. Conclusions The variables of significant social history, low English language proficiency, incomplete discharge documentation, and delay in issuing the discharge summary add value to prediction models. What is known about the topic? Despite written discharge documentation playing a critical role in the continuity of care for paediatric patients, limited research has examined its association with, and ability to predict, unplanned hospital readmissions. Machine learning approaches have been applied to various health conditions and demonstrated improved predictive accuracy. However, few published studies have used machine learning to predict paediatric readmissions. What does this paper add? This paper presents the findings of the first known study in Australia to assess and report that written discharge documentation and clinical information improves unplanned rehospitalisation prediction accuracy in a paediatric cohort compared with administrative data alone. It is also the first known published study to use machine learning for the prediction of paediatric same-hospital unplanned readmission in Australia. The results show improved predictive performance of the machine learning approach compared with standard logistic regression. What are the implications for practitioners? The identified social and written discharge documentation predictors could be translated into clinical practice through improved discharge planning and processes, to prevent paediatric 30-day all-cause same-hospital unplanned readmission. The predictors identified in this study include significant social history, low English language proficiency, incomplete discharge documentation, and delay in issuing the discharge summary.
Topics: Australia; Case-Control Studies; Child; Documentation; Humans; Machine Learning; Medical Records; Patient Discharge; Patient Readmission; Retrospective Studies; Risk Factors; Western Australia
PubMed: 33840419
DOI: 10.1071/AH20062 -
Journal of Hospital Medicine Jan 2022Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods...
BACKGROUND
Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown.
OBJECTIVE
The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality.
DESIGNS
Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention.
SETTINGS AND PARTICIPANTS
Admission notes written by University of Cincinnati interns were assessed.
INTERVENTIONS
The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback.
MAIN OUTCOMES AND MEASURES
Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT).
RESULTS
Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (β = .08, p = .03 and β = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time.
CONCLUSION
Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.
Topics: Curriculum; Documentation; Electronic Health Records; Hospitalization; Humans; Internal Medicine
PubMed: 35504574
DOI: 10.1002/jhm.27410 -
Archives of Disease in Childhood. Fetal... Mar 2020To assess the accuracy of real-time delivery room resuscitation documentation. (Observational Study)
Observational Study
OBJECTIVE
To assess the accuracy of real-time delivery room resuscitation documentation.
DESIGN
Retrospective observational study.
SETTING
Level 3 academic neonatal intensive care unit.
PARTICIPANTS
Fifty infants with video recording of neonatal resuscitation.
MAIN OUTCOME MEASURES
Vital sign assessments and interventions performed during resuscitation. The accuracy of written documentation was compared with video gold standard.
RESULTS
Timing of initial heart rate assessment agreed with video in 44/50 (88%) records; the documented heart rate was correct in 34/44 (77%) of these. Heart rate and oxygen saturation were documented at 5 min of life in 90% of resuscitations. Of these, 100% of heart rate and 93% of oxygen saturation values were correctly recorded. Written records accurately reflected the mode(s) of respiratory support for 89%-100%, procedures for 91%-100% and medications for 100% of events.
CONCLUSION
Real-time documentation correctly reflects interventions performed during delivery room resuscitation but is less accurate for early vital sign assessments.
Topics: Academic Medical Centers; Delivery Rooms; Documentation; Heart Rate; Humans; Infant, Newborn; Intensive Care Units, Neonatal; Oxygen; Resuscitation; Retrospective Studies; Time Factors; Video Recording
PubMed: 30472661
DOI: 10.1136/archdischild-2018-315723 -
Journal of Pediatric Orthopedics 2019Supracondylar fractures of the humerus (SCH) are the most common fractures about the elbow in children that require operative stabilization. Considering the possible...
BACKGROUND
Supracondylar fractures of the humerus (SCH) are the most common fractures about the elbow in children that require operative stabilization. Considering the possible complications involved including nerve deficit and compartment syndrome, documentation is crucial to good patient care. It also is of prime importance for justification or defense of our care should this arise. One of the common concerns in transition from written documentation to an electronic medical record (EMR) is availability of proper documentation. We sought to develop an established EMR protocol to streamline and improve proper care and documentation for SCH fractures. This was in response to poor documentation in an initial retrospective evaluation.
METHODS
Documentation before and after the implementation of a clinical pathway were compared. A retrospective chart review was used to collect documentation information before the implementation of the clinical pathway and a prospective study design was used to collect information after the implementation of the clinical pathway. Proportions of preclinical and postclinical pathway documentation were compared before and after the implementation of the clinical pathway using a χ test, or the Fisher exact test for measures in which at least 20% of the expected frequencies were <5. A 2-sided 0.05 α level was used to define statistical significance.
RESULTS
We saw an improvement in documentation after implementation of the clinical pathway, with statistically significant differences in nursing preoperative, physician preoperative, and physician postoperative. Nursing postanesthesia care unit, nursing postoperative, and physician clinic follow-up trended toward improvement but did not meet statistical significance. Although we did see improvement, we still did not meet ideal 100% documentation in all categories.
CONCLUSIONS
Documentation is crucial to good medical care and legal defense should any arise. The implementation of a clinical pathway demonstrated significant improvement by physicians and nurses. Although overall improvement was obtained, there were areas associated with EMR identified that still require further improvement.
LEVEL OF EVIDENCE
Level III.
Topics: Child; Child, Preschool; Critical Pathways; Documentation; Elbow Joint; Electronic Health Records; Female; Humans; Humeral Fractures; Infant; Male; Medical Staff, Hospital; Nursing Staff, Hospital; Postoperative Complications; Prospective Studies; Quality Improvement; Retrospective Studies
PubMed: 31095013
DOI: 10.1097/BPO.0000000000001372 -
Health Physics May 2017The definitions of "radiation area," "high radiation area," and "very high radiation area," provided by the U.S. Department of Energy in 10 CFR Part 835.2, and by the...
The definitions of "radiation area," "high radiation area," and "very high radiation area," provided by the U.S. Department of Energy in 10 CFR Part 835.2, and by the Nuclear Regulatory Commission in 10 CFR Part 20.1003, appear to require redundant posting. This is counterintuitive and would be confusing if the regulations were followed as currently written. We suspect that this is unintentional. However, until the relevant regulations are revised, it is recommended that licensees request written clarification from the regulators to ensure that they are able to demonstrate regulatory compliance.
Topics: Documentation; Government Agencies; Government Regulation; Guideline Adherence; Mandatory Reporting; Radiation Protection; Terminology as Topic; United States
PubMed: 28350706
DOI: 10.1097/HP.0000000000000661