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Journal of Health Care Chaplaincy 2022Medical record documentation by hospital chaplains is an under-researched and under-published field. Because documentation serves both as a register of chaplain...
Medical record documentation by hospital chaplains is an under-researched and under-published field. Because documentation serves both as a register of chaplain interventions and as a collaborative tool for interdisciplinary communication, it should be written in a way that is clear, concise, and consistent. As chaplains continue to integrate with other medical professions in interdisciplinary care, careful attention should be given to the way in which communication of the chaplain role, functioning, and patient information obtained is conveyed. This quality improvement project standardized chaplain documentation in one health system of 15 medical centers, provides insights and resources devised from the project, and offers considerations for other systems contemplating future changes toward standardizing documentation.
Topics: Clergy; Communication; Documentation; Electronic Health Records; Humans; Quality Improvement
PubMed: 33369536
DOI: 10.1080/08854726.2020.1861534 -
Scandinavian Journal of Caring Sciences Sep 2014The admission interview is usually the first structured meeting between patient and nurse. The interview serves as the basis for personalised nursing and care planning...
The admission interview is usually the first structured meeting between patient and nurse. The interview serves as the basis for personalised nursing and care planning and is the starting point for the clinic's documentation of the patient and his course of treatment. In this way, admission interviews constitute a basis for reporting by each nurse on the patient to nursing colleagues. This study examined how, by means of the admission interview, nurses constructed written documentation of the patient and his course of treatment for use by fellow nurses. A qualitative case study inspired by Ricoeur was conducted and consisted of five taped admission interviews, along with the written patient documentation subsequently worked out by the nurse. The findings were presented in four constructed themes: Admission interviews are the nurse's room rather than the patient's; Information on a surgical object; The insignificant but necessary contact; and Abnormalities must be medicated. It is shown how the nurse's documentation was based on the admission interview, the medical record details on the patient (facts that are essential to know in relation to disease and treatment), as well as the nurse's preconception of how to live a good life, with or without disease. Often, the patient tended to become an object in the nurse's report. It is concluded that in practice, the applied documentation system, VIPS, comes to act as the framework for what is important to the nurse to document rather than a tool that enables her to document what is important to the individual patient and his special circumstances and encounter with the health system.
Topics: Documentation; Nurse-Patient Relations; Nursing Process; Patient Admission
PubMed: 24033872
DOI: 10.1111/scs.12071 -
International Journal of Older People... Sep 2022Person-centred care is a growing imperative in healthcare, but the documentation of person-centred care is challenging. According to the Gothenburg Framework of... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Person-centred care is a growing imperative in healthcare, but the documentation of person-centred care is challenging. According to the Gothenburg Framework of Person-centred Care, care should be documented in continuously revised care plans and based on patients' personally formulated goals and resources to secure a continuous partnership.
OBJECTIVES
This study aimed to examine care plans produced within a randomised controlled trial that tested a person-centred care intervention in older people with acute coronary syndrome. Nurses with training in the theory and practice of person-centred care had written the care plans.
METHODS
We conducted a secondary analysis of care plans developed in a randomised controlled trial for assessing person-centred care in patients with acute coronary syndrome (Myocardial Infarct [MI] or unstable angina pectoris). The study sample included 84 patients, with three care plans for each patient from inpatient (T1), outpatient (T2) and primary care (T3), that is, a total of 252 care plans. We conducted a descriptive quantitative content analysis of the care plans to examine the reported patients' life-world and medical/health resources and goals.
RESULTS
The analysis illustrates the differences and overlaps between life-world and medical/health goals and resources. The documented goals and resources change over time: life-world goals and resources decreased with time as medical/health goals and resources documentation increased.
CONCLUSIONS
This paper illustrates that in the setting of a randomised controlled trial, nurses with training in person-centred care recorded fewer life-world and more medical/health goals over time. Placing life-world goals at the top of the goal hierarchy enables alignment with medical/health goals. Further research should explore whether the goals and resources documented in care plans accurately reflect patients' wishes as they transition along the care chain.
TRIAL REGISTRATION
Swedish registry, Researchweb.org, ID NR 65 791.
Topics: Acute Coronary Syndrome; Aged; Delivery of Health Care; Documentation; Humans; Nursing Care; Patient-Centered Care
PubMed: 35393772
DOI: 10.1111/opn.12461 -
BMC Medical Education Oct 2022Composing the History of Present Illness (HPI), a key component of medical communication, requires critical thinking. Small group learning strategies have demonstrated... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Composing the History of Present Illness (HPI), a key component of medical communication, requires critical thinking. Small group learning strategies have demonstrated superior effectiveness at developing critical thinking skills. Finding sufficient faculty facilitators for small groups remains a major gap in implementing these sessions. We hypothesized that "near-peer" teachers could effectively teach HPI documentation skills and fill the gap of small group facilitators. Here, we present a head-to-head comparison of near-peer and faculty teaching outcomes.
METHODS
Second-year medical students in a single institution participated in an HPI Workshop as a clinical skills course requirement. Students were randomly assigned a near-peer or faculty facilitator for the workshop. We compared mean facilitator evaluation scores and performance assessments of students assigned to either type of facilitator.
RESULTS
Three hundred sixty-five students, 29 residents (near-peers) and 16 faculty participated. On post-session evaluations (5-point Likert scale), students ranked near-peer facilitators higher than faculty facilitators on encouraging participation and achieving the goals of the session (residents 4.9, faculty 4.8), demonstrating small, statistically significant differences between groups. Mean scores on written assessments after the workshop did not differ between the groups (29.3/30 for a written H&P and 9/10 for an HPI exam question).
CONCLUSIONS
Near-peer facilitators were as effective as faculty facilitators for the HPI Workshop. Utilizing near-peers to teach HPI documentation skills provided teaching experiences for residents and increased the pool of available facilitators.
Topics: Clinical Competence; Documentation; Humans; Peer Group; Students, Medical; Teaching; Thinking
PubMed: 36209076
DOI: 10.1186/s12909-022-03790-0 -
Journal of Orthopaedic Surgery and... Jan 2023The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current...
OBJECTIVES
The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes.
METHODS
A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes.
RESULTS
Ninety-seven cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the freehand op-note group (templated median 14, range 12-14, vs. freehand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by consultants or trainees identified trainees as more likely to document the antibiotic prophylaxis given (p = 0.025).
CONCLUSIONS
Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.
Topics: Humans; Orthopedics; Orthopedic Procedures; Documentation; Surgeons; Femoral Neck Fractures
PubMed: 36647146
DOI: 10.1186/s13018-022-03484-9 -
JEMS : a Journal of Emergency Medical... May 2008
Topics: Decision Making; Documentation; Emergency Medical Services; Emergency Medical Technicians; Humans; Memory
PubMed: 18482647
DOI: 10.1016/S0197-2510(08)70186-4 -
The Journal of Surgical Research Jun 2017Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication...
BACKGROUND
Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities.
METHODS
We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated.
RESULTS
A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided.
CONCLUSIONS
This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers.
Topics: Communication; Documentation; Emergency Service, Hospital; General Surgery; Humans; Medical Records; Patient Transfer; Quality Assurance, Health Care; Quality Indicators, Health Care; Retrospective Studies; Wisconsin
PubMed: 28624064
DOI: 10.1016/j.jss.2017.02.069 -
Critical Care Nursing Quarterly Aug 2000Critical care nurses may encounter a victim of domestic violence or abuse when caring for an individual with traumatic injuries. Understanding the injuries that are... (Review)
Review
Critical care nurses may encounter a victim of domestic violence or abuse when caring for an individual with traumatic injuries. Understanding the injuries that are associated with acts of violence is only the first step. A vital part of the nurse's responsibilities is the precise written documentation of observations, physical assessments, and other factors that may later become vital evidence in a court of law.
Topics: Documentation; Female; Humans; Nursing Assessment; Spouse Abuse; Terminology as Topic; Wounds and Injuries
PubMed: 11853024
DOI: 10.1097/00002727-200008000-00004 -
Perspectives in Biology and Medicine 2018A growing demand for transparency in medicine has the potential to strain the doctor-patient relationship. While information can empower patients, unrestricted patient...
A growing demand for transparency in medicine has the potential to strain the doctor-patient relationship. While information can empower patients, unrestricted patient access to the electronic medical record may have unintended consequences. Medical documentation is often written in language that is inaccessible to people without medical training, and without guidance, patients have no way to interpret the constellation of acronyms, diagnoses, treatments, impressions, and arguments that appear throughout their own chart. Additionally, full transparency may not allow physicians the intellectual or clinical freedom they need to authentically express questions, problematic impressions, and concerns about the patient's clinical and psychosocial issues. This article examines the ethical challenges of transparency in the digital era and suggests that selective redaction may serve as a means to maintain transparency, affirm physician's discretion, and uphold the core values of the doctor-patient relationship amidst disruptive technological change.
Topics: Documentation; Electronic Health Records; Humans; Physician-Patient Relations
PubMed: 29805152
DOI: 10.1353/pbm.2018.0031 -
Southern Medical Journal May 2009Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two...
Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.
Topics: Adult; Black or African American; Anti-Asthmatic Agents; Asthma; Documentation; Emergency Service, Hospital; Female; Hospitals, University; Humans; Male; Medical Audit; Medical Records; Patient Discharge; Patient Education as Topic; Practice Guidelines as Topic; Self Administration; Urban Population
PubMed: 19373150
DOI: 10.1097/SMJ.0b013e31819ecb03