-
AMIA ... Annual Symposium Proceedings.... 2021Working with scribes can reduce provider documentation time, but few studies have examined how scribes affect clinical notes. In this retrospective cross-sectional...
Working with scribes can reduce provider documentation time, but few studies have examined how scribes affect clinical notes. In this retrospective cross-sectional study, we examine over 50,000 outpatient progress notes written with and without scribe assistance by 70 providers across 27 specialties in 2017-2018. We find scribed notes were consistently longer than those written without scribe assistance, with most additional text coming from note templates. Scribed notes were also more likely to contain certain templated lists, such as the patient's medications or past medical history. However, there was significant variation in how working with scribes affected a provider's mix of typed, templated, and copied note text, suggesting providers adapt their documentation workflows to varying degrees when working with scribes. These results suggest working with scribes may contribute to note bloat, but that providers' individual documentation workflows, including their note templates, may have a large impact on scribed note contents.
Topics: Cross-Sectional Studies; Documentation; Electronic Health Records; Humans; Outpatients; Retrospective Studies
PubMed: 35309010
DOI: No ID Found -
General Hospital Psychiatry 2018The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is... (Review)
Review
OBJECTIVE
The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is an inherently risk-assuming action. The rationale and conduct of the therapeutic discharge has been written on previously. Here, we propose a method of documenting the therapeutic discharge in a way that is useful and teachable.
METHOD
After describing some other types of note-writing that can be needed in the care of deceptive patients, we describe an approach to each of the major sections of an initial consultation/encounter note as it applies to the therapeutic discharge.
RESULTS
Each note section is handled slightly differently than ordinarily. The history of present illness follows the sequence, rather than the re-organization of the information obtained. The past medical history requires and reflects a more granular chart review than is usually warranted. The mental status exam is less cross-sectional than usual. The assessment and plan incorporates several components that reflect a reasoning process specific to the therapeutic discharge.
CONCLUSION
While labor-intensive, the documentation approach advocated for and exemplified here reaffirms aspects of one's identity as a physician, ensures responsible execution of a risk-involving decision, and potentially simplifies subsequent patient encounters.
Topics: Documentation; Humans; Malingering; Mental Disorders; Patient Discharge; Suicidal Ideation
PubMed: 29309988
DOI: 10.1016/j.genhosppsych.2017.12.007 -
Academic Psychiatry : the Journal of... 2010
Topics: Accreditation; Clinical Competence; Documentation; Humans; Internship and Residency; Michigan; Program Evaluation; Psychiatry
PubMed: 20224032
DOI: 10.1176/appi.ap.34.2.158 -
Bratislavske Lekarske Listy 2017The objective of the work was to identify if health documentation management is depending of actually current legislation. Also to review range and consistency records....
OBJECTIVES
The objective of the work was to identify if health documentation management is depending of actually current legislation. Also to review range and consistency records. The work described forms and content of documentation, relating to treat wounds and decubitus.
METHODS
A content analysis of 139 health documentation of insurer of General Health Insurance Company, which were treated by 28 home care agencies (hereinafter "HCA") and in the HCA was done directly audit in 2012 and 2014. We set 29 assessment items, with criteria separation according structure, process and outcome. Documentation, we analyzed three ways: through 5 grade rating scale, by choosing a clear answer to the question: yes, no and evaluation of specific items of documentation.
RESULTS
The research confirm dependence keeping medical records in home nursing care agencies from legislation. On the other hand, it was found that the form of the recording method of health care in many cases are varied and fragmented. Deficiencies were found in the area of criteria such as structure, process and outcomes and transparency in the management of documentation pressure ulcers and chronic wounds. Only 62.9 % of the documentations was written nursing care and sent to Health Insurance Company in full compliance or with minor shortcomings.
CONCLUSION
Research has shown that in the legislation defined by standard forms was recorded the lowest number of deficiencies. This fact needs to be used for the development of new legislation, which directed to setting documentation with clearly defined, structured information's. WHO adopted the International Classification for Nursing Practice (ICNP) as essential and complementary part of professional health services (Tab. 2, Fig. 2, Ref. 22).
Topics: Clinical Audit; Documentation; Home Care Agencies; Humans; Insurance, Health; Medical Records; Pressure Ulcer; Slovakia; Wounds and Injuries
PubMed: 28319416
DOI: 10.4149/BLL_2017_037 -
Journal of Medical Systems Jul 2022The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient...
The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient records (EPR) are a substantial part in this transformation, even though their influence on documentation remains often unclear. This review aims to answer the question of which effect the introduction of the EPR has on the documentation proper in hospitals. To do this, studies are reviewed that analyze the documentation itself, rather than merely conducting interviews or surveys about it. Several databases were searched in this systematic review (PubMed including PubMed, PubMed Central and Medline; PDQ Evidence; Web of Science Core Collection; CINHAL). To be included, studies needed to analyze written documentation and empirical data, be in either German or English language, published between 2010 and 2020, conducted in a hospital setting, focused on transition from paper-based to electronic patient records, and peer reviewed. Quantitative, qualitative and mixed methods studies were included. Studies were independently screened for inclusion by two researchers in three stages (title, abstract, full text) and, in case of disagreement, discussed with a third person from the research team until consensus was reached. The main outcome assessed was whether the studies indicated a negative or positive effect on documentation (e.g. changing the completeness of documentation) by introducing an EPR. Mixed Methods Appraisal Tool was used to assess the individual risk of bias in the included studies. Overall, 264 studies were found. Of these, 17 met the inclusion criteria and were included in this review. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation such as an improved completeness or guideline adherence of the documentation. Six of 17 showed a mixed effect with positive and negative or no changes. No study showed an exclusively negative effect. Most studies found a positive effect of EPR introduction on documentation. However, it is difficult to draw specific conclusions about how the EPR affects or does not affect documentation since the included studies examined a variety of outcomes. As a result, various scenarios are conceivable with higher or reduced burden for practitioners. Additionally, the impact on treatment remains unclear.
Topics: Documentation; Electronic Health Records; Hospitals; Humans
PubMed: 35781136
DOI: 10.1007/s10916-022-01840-0 -
BMJ Open Quality Feb 2021Medical records are crucial facet of a patient's journey. These provide the clinician with a permanent record of the patient's illness and ongoing medical care, thus...
Medical records are crucial facet of a patient's journey. These provide the clinician with a permanent record of the patient's illness and ongoing medical care, thus enabling informed clinical decisions. In many hospitals, patient medical records are written on paper. However, written notes are liable to misinterpretation due to illegibility and misplacement. This can affect the patient's medical care and has medico-legal implications. Electronic patient records (EPR) have been gradually introduced to replace patient's paper notes with the aim of providing a more reliable record-keeping system. It is perceived that EPR improve the quality and efficiency of patient care. The paediatric department at Queen's Hospital Burton uses a mix of paper notes and computerised medical records. Clinicians primarily use paper notes for admission clerking, ward rounds, ward reviews and outpatient clinic consultations. Laboratory tests, imaging results and prescription requests are executed via the EPR system. Documentation by nurses is also carried out electronically. We aimed to improve and standardise clinical documentation of paediatric admissions and ward round notes by developing electronic proforma for initial paediatric clerking, ward rounds and patient reviews. This quality improvement project improved clinical documentation on the paediatric wards and enhanced patient record-keeping, boosted clinical information-sharing and streamlined patient journey. It fulfilled various generic multidisciplinary record keeping audit tool standards endorsed by the Royal College of Physicians by 100%. We undertook a staff survey to investigate the opinion before and after implementing the electronic health record. Doctors, nurses and healthcare support workers overwhelmingly supported the quality, usefulness, completeness of specified fields and practicality of the electronic records.
Topics: Child; Documentation; Electronic Health Records; Hospitals; Humans; Pediatrics; Quality Improvement
PubMed: 33589503
DOI: 10.1136/bmjoq-2020-000918 -
Journal of Clinical Nursing Sep 2011To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice. (Review)
Review
AIM
To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.
BACKGROUND
Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.
DESIGN
Systematic review.
METHOD
MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.
RESULTS
In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.
CONCLUSION
General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.
RELEVANCE TO CLINICAL PRACTICE
This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.
Topics: Documentation; Nursing Diagnosis
PubMed: 21676043
DOI: 10.1111/j.1365-2702.2010.03573.x -
Annales de Chirurgie Plastique Et... Dec 2014In rhinoplasty, satisfying the patient both aesthetically and functionally can be complex. In aesthetic surgery, the rhinoplastician has a reinforced obligation of...
In rhinoplasty, satisfying the patient both aesthetically and functionally can be complex. In aesthetic surgery, the rhinoplastician has a reinforced obligation of means. In our experience, the functional outcome of the patient is closely linked to the morphological result. When a rhinoplasty provides the patient with full aesthetic satisfaction, even if he/she has breathing difficulties, there will be very few disputes. In primary rhinoplasty, unsatisfactory results occur in 15%-30% of the cases. While orally informing the patient is paramount, the practitioner must also have written proof of the information via documents given or sent to the various players including the patient. The taking of pre- and postoperative photographs is essential and the surgeon must keep them on file for support in case of conflict.
Topics: Documentation; Esthetics; Expert Testimony; France; Humans; Informed Consent; Malpractice; Patient Education as Topic; Patient Satisfaction; Referral and Consultation; Rhinoplasty
PubMed: 25179863
DOI: 10.1016/j.anplas.2014.07.020 -
Bioinformatics (Oxford, England) May 2023Increases in the cohort size in long-read sequencing projects necessitate more efficient software for quality assessment and processing of sequencing data from Oxford...
SUMMARY
Increases in the cohort size in long-read sequencing projects necessitate more efficient software for quality assessment and processing of sequencing data from Oxford Nanopore Technologies and Pacific Biosciences. Here, we describe novel tools for summarizing experiments, filtering datasets, visualizing phased alignments results, and updates to the NanoPack software suite.
AVAILABILITY AND IMPLEMENTATION
The cramino, chopper, kyber, and phasius tools are written in Rust and available as executable binaries without requiring installation or managing dependencies. Binaries build on musl are available for broad compatibility. NanoPlot and NanoComp are written in Python3. Links to the separate tools and their documentation can be found at https://github.com/wdecoster/nanopack. All tools are compatible with Linux, Mac OS, and the MS Windows Subsystem for Linux and are released under the MIT license. The repositories include test data, and the tools are continuously tested using GitHub Actions and can be installed with the conda dependency manager.
Topics: Humans; Software; Sequence Analysis, DNA; High-Throughput Nucleotide Sequencing; Nanopores; Documentation
PubMed: 37171891
DOI: 10.1093/bioinformatics/btad311 -
Patient Education and Counseling Aug 2019To integrate findings on the information infrastructure for people with intellectual or developmental disability (I/DD) living in supported accommodation, to understand... (Review)
Review
OBJECTIVES
To integrate findings on the information infrastructure for people with intellectual or developmental disability (I/DD) living in supported accommodation, to understand how documentation use impacts person-centred support.
METHODS
We conducted an integrative literature review. Following screening by two independent reviewers, we included English language peer-reviewed empirical studies (n = 34) on documentation use for people with I/DD in domestic-scale supported accommodation. We appraised quality and extracted information for iterative comparative thematic and content analysis.
RESULT
All studies reported written documentation regarding either the person with disability or the residence. Eighteen studies focused on health-specific information. We identified three key themes impacting on the person-centred support; 1) level of inclusion and independence of people with I/DD, 2) the culture of support within group homes, and 3) the quality use of information.
CONCLUSIONS
Information infrastructure is closely aligned with the support culture in residences and can affect whether and to what extent key stakeholders (i.e., people with I/DD, family members) are involved in making decisions about healthcare and support needs.
PRACTICE IMPLICATIONS
Surveying local service health information infrastructure can provide crucial insights which can be leveraged to improve the safety and quality of supports provided for people living in supported accommodation.
Topics: Decision Making; Disabled Persons; Documentation; Humans; Organizational Culture; Patient Safety; Patient-Centered Care; Quality Improvement; Residential Facilities
PubMed: 31010602
DOI: 10.1016/j.pec.2019.03.008