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Journal of Athletic Training Feb 2024Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training, leaving individual organizations responsible for...
CONTEXT
Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training, leaving individual organizations responsible for setting expectations and enforcing policies. Previous research has examined clinician documentation behaviors; however, the supervisor's role in creating policy and procedures, communicating expectations, and ensuring accountability has not been investigated.
OBJECTIVE
To investigate supervisor practices regarding support, hindrance, and enforcement of medical documentation standards at an individual organization level.
DESIGN
Mixed-methods study.
SETTING
Online surveys and follow-up interviews.
PATIENTS OR OTHER PARTICIPANTS
We criterion sampled supervising athletic trainers (n = 1107) in National Collegiate Athletic Association member schools. The survey collected responses from 64 participants (age = 43 ± 11 years; years of experience as a supervisor = 12 ± 10; access rate = 9.6%; completion rate = 66.7%), and 12 (age = 35 ± 6 years; years of experience as a supervisor = 8 ± 5) participated in a follow-up interview.
DATA COLLECTION AND ANALYSIS
We used measures of central tendency to summarize survey data and the consensual qualitative research approach with a 3-person data analysis team and multiphase process to create a consensus codebook. We established trustworthiness using multiple-analyst triangulation, member checking, and internal and external auditing.
RESULTS
Fewer than half of supervisors reported having formal written organization-level documentation policies (n = 45/93, 48%) and procedures (n = 32/93, 34%) and an expected timeline for completing documentation (n = 24/84, 29%). Participants described a framework relative to orienting new and existing employees, communicating policies and procedures, strategies for holding employees accountable, and identifying purpose. Limitations included lack of time, prioritization of other roles and responsibilities, and assumptions of prior training and record quality.
CONCLUSION
Despite a lack of clear policies, procedures, expectations, prioritization, and accountability strategies, supervisors still felt confident in their employees' abilities to create complete and accurate records. This highlights a gap between supervisor and employee perceptions, as practicing athletic trainers have reported uncertainty regarding documentation practices in previous studies. Although supervisors perceive high confidence in their employees, clear organization standards, employer prioritization, and mechanisms for accountability surrounding documentation will result in improved patient care delivery, system outcomes, and legal compliance.
Topics: Humans; Adult; Middle Aged; Motivation; Schools; Patient Care; Sports; Documentation; Surveys and Questionnaires; Qualitative Research
PubMed: 37459373
DOI: 10.4085/1062-6050-0062.23 -
British Journal of Community Nursing Feb 2024Iwan Dowie discusses the need for appropriate record keeping in community nursing. Through a series of legal examples, a case is made for good documentation, with...
Iwan Dowie discusses the need for appropriate record keeping in community nursing. Through a series of legal examples, a case is made for good documentation, with suggestions that include factual, eligible and well-written records.
Topics: Humans; Documentation; Nursing Care
PubMed: 38300239
DOI: 10.12968/bjcn.2024.29.2.58 -
Nursing Open Mar 2023Pressure ulcers cause suffering, prolong care periods, and increase mortality. The aim was to describe and analyze the documentation of pressure ulcers and focused on...
OBJECTIVES
Pressure ulcers cause suffering, prolong care periods, and increase mortality. The aim was to describe and analyze the documentation of pressure ulcers and focused on the medical records from an internal medicine ward in a university hospital in western Sweden.
METHODS
A quantitative, retrospective review of medical records was conducted for all care events (n = 1,458) with descriptive statistics.
RESULTS
Documentation of the pressure ulcers in care plans was 2.1% (n = 31) compared to 6.7 % (n = 46) within final notes written by registered nurses (RN), a lower result compared to PPM (n = 3/14, 21.4%). Risk assessments were carried out in 68 (4.7%) care events, and 31 care plans included pressure ulcers. Moreover, 198 cases of tissue damage were documented, 43 (21.7%) defined as pressure ulcers, the other 147 (74.2%) lacked definition.
CONCLUSIONS
Differences (2.1%-21.4%) highlight improvements; knowledge and communication of pressure ulcers ensure reliable documentation in medical records.
Topics: Humans; Pressure Ulcer; Sweden; Nursing Records; Medical Records; Hospitals, University; Documentation
PubMed: 36303218
DOI: 10.1002/nop2.1439 -
Current Diabetes Reviews 2019The documentation of medical records of diabetic patients is very important for the treatment of diabetes. The purpose of this study was to conduct quantitative...
BACKGROUND
The documentation of medical records of diabetic patients is very important for the treatment of diabetes. The purpose of this study was to conduct quantitative evaluations of the Diabetic Medical Record (DMR) and Documentation Completeness Rate (DCR).
METHODS
In this retrospective study, we evaluated the DCR of DMRs in the Comprehensive Diabetes Center of Imam Reza Hospital (CDRIRH). A checklist was prepared to evaluate the DCR. The overall assessment of the DCR was represented according to the following rating: 95-100% as strong, 75-94% as moderate, and less than 75% as weak. The free texts that physicians recorded in the DMRs were extracted to identify the data elements that physicians must record. In addition, the clinical importance of the data elements of the DMRs from the perspective of the endocrinologists was determined and then compared with the DCR.
RESULTS
In this study, 1,200 DMRs and DCRs for 50 data elements in eight major categories were evaluated. The total DCR average was 30% and data elements in the laboratory test results category demonstrated the highest DCR (50.5%), whereas the least percentage was demonstrated in the internal visits category. The DCR for the other main categories was: demographic information = 48.5%; patient referral information = 14.2%; diagnosis = 5%; anti-hyperglycemic medications = 25.5%; diabetic complications = 17.7%; and results of specialty and subspecialty consultation = 41.7%. The evaluation of the free text data element in the DMRs indicated that physicians documented free text data elements in three categories.
CONCLUSION
Our results demonstrated a weak level of documentation in the DMRs. The physicians had written many data elements in the margins of the DMRs. Therefore, it indicates the necessity to modify and change the structure of the DMR.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Checklist; Child; Child, Preschool; Diabetes Mellitus; Documentation; Female; Humans; Iran; Male; Medical Records; Middle Aged; Retrospective Studies; Young Adult
PubMed: 29932036
DOI: 10.2174/1573399814666180622161309 -
Emergency Medical Services Oct 2002Persons who activate an EMS system expect a timely response from people who will be able to help them. When they don't get the service they are expecting, they may look...
Persons who activate an EMS system expect a timely response from people who will be able to help them. When they don't get the service they are expecting, they may look for legal recourse. Hospital staff and healthcare providers expect prehospital care providers to follow protocols and standing orders in providing interventions to help stabilize conditions found during patient assessments. The results of these interventions must be conveyed via both oral and written documentation. Documentation of patient care, equipment maintenance, inventory control and training can help protect the assets of an EMS organization. It can help prove (in a court of law, if necessary) that the organization acted in a prudent manner. Documentation becomes the history of the organization. Does your history show that you are a professional organization?
Topics: Documentation; Efficiency, Organizational; Emergency Medical Services; Equipment and Supplies; Humans; Inservice Training; Maintenance; Records; United States
PubMed: 12683278
DOI: No ID Found -
International Journal of Nursing Studies Nov 1992In this case study, the views of a sample of four hospital nurses were elicited to determine underlying causes of persistent antipathy towards documentation in patients'... (Review)
Review
In this case study, the views of a sample of four hospital nurses were elicited to determine underlying causes of persistent antipathy towards documentation in patients' charts. The results of this review supported a common belief that resistance to charting is influenced by extrinsic, or environmental factors, such as inflexibility of charting systems and insufficient allocation of time. In addition, intrinsic factors or cognitive and psychosocial factors, not emphasized in earlier studies, such as lack of confidence about written expression, a tendency to succumb to group norms governing charting and difficulty in articulating the nature of nursing practice, surfaced as impediments to documentation. This review suggests that a broader study approach is required; one that addresses intrinsic, as well as extrinsic, factors.
Topics: Adult; Attitude of Health Personnel; Case-Control Studies; Documentation; Female; Humans; Nursing Evaluation Research; Nursing Records; Nursing Staff, Hospital; Patient Care Planning; Time Factors; Writing
PubMed: 1428602
DOI: 10.1016/0020-7489(92)90015-9 -
Emergency Medical Services Apr 2001Patient morbidity and mortality, subsequent to either patient- or provider-initiated refusals, are noteworthy. It has been estimated that hospital admission is twice as...
Patient morbidity and mortality, subsequent to either patient- or provider-initiated refusals, are noteworthy. It has been estimated that hospital admission is twice as likely after prehospital providers refuse a patient transportation to the hospital. In one particular study group, prehospital-provider refusal of transportation, as opposed to patient refusal of transportation, accounted for 73% of the post-refusal hospital admissions. Provider-initiated refusals are tantamount to a time bomb. There are very few justifiable provider-initiated refusals of treatment or transportation. If the call is of a non-emergency nature, the decision not to treat or transport should be a mutual agreement between the patient and provider. Consult with the online medical director for guidance as needed. Document the physician's name, consulting facility and medical direction. As with every patient encounter, a legally defensible runsheet should be completed. Should you write a report if your services are "not needed," or if you are canceled en route to the call? For your protection, a report archiving every run should be documented. If your services are canceled en route, note the canceling authority and time of cancellation. If your services are canceled at the scene, document the canceling authority, time of cancellation and the circumstance. It is important to specifically document that "no patient contacts were made." When patient contact is made, a patient-provider relationship is established, thereby redefining your duty to the patient. Protect yourself, your crew members, your chain of command, your jurisdiction and your agency by writing a legally defensible informed refusal report. According to one source, "Every negligence case in the last 30 years has been decided on its documentation." If it wasn't written down, it wasn't done. Be safe, and document safely.
Topics: Documentation; Emergency Medical Services; Humans; Informed Consent; Liability, Legal; Mental Competency; Treatment Refusal; United States
PubMed: 11383168
DOI: No ID Found -
Clinical Toxicology (Philadelphia, Pa.) Nov 2020There is little research examining clinician adherence to specialist toxicological phone advice. Efforts to improve adherence should be sought to optimise the...
There is little research examining clinician adherence to specialist toxicological phone advice. Efforts to improve adherence should be sought to optimise the management of poisoned patients. This study aimed to determine if contemporaneous documentation in the patient electronic medical record (EMR) improved adherence to Poisons Information Centre (PIC) advice. This was a prospective before and after observational study following the implementation of documented poisoning management advice by PIC staff into the patient's EMR. Advice adherence was assessed following a review of the patient medical records and designated to complete adherence, minor discrepancies not affecting patient care, major discrepancies affecting patient care and non-adherence. The primary outcome was the proportion of satisfactory (complete adherence/minor discrepancies) adherence. Secondary outcomes included the accuracy of documented telephone advice by the treating clinician, the number of case recalls and episodes of sub-optimal management. A total of 980 cases (347 in the pre-intervention phase and 633 in the post-intervention phase) were included in the study, of which 350 had PIC EMR documentation performed. Documented call advice by the treating clinician was absent in 41 of 347 cases (11.8%) cases and inaccurate in 42 of 306 cases (13.7%). Following PIC documentation, satisfactory adherence improved from 304/347(87.6%) to 333/350(95.1%)(difference 7.5% [95% CI 3.1% to 11.9%]), with suboptimal management decreasing from 48/347(13.8%) to 14/350(4%)(difference - 9.8% [95% CI -5.5% to -14.4%]). Recalls were similar in both periods. The median time to enter advice into the EMR was 26 min (IQR: 14-45 min). The main reason for not documenting advice was that the PIC staff member was working a solo shift with a prohibitively heavy workload. EMRs enable PICs to supplement verbal advice with written documentation, offering an opportunity to improve communication and enable better handover of clinical information. Documentation of advice by PIC staff in the patient medical record was associated with improved advice adherence and reduced sub-optimal management.
Topics: Documentation; Electronic Health Records; Humans; Information Centers; Poisoning; Prospective Studies; Referral and Consultation; Telephone
PubMed: 32141792
DOI: 10.1080/15563650.2020.1728297 -
BMJ Open Quality Sep 2021It is estimated that 1 in 10 hospital inpatients in Scotland have experienced a medication error. In our unit, an audit in 2019 identified documentation of as-required...
It is estimated that 1 in 10 hospital inpatients in Scotland have experienced a medication error. In our unit, an audit in 2019 identified documentation of as-required prescriptions on drug Kardexes as an important target for improvement. This project aimed to reduce the percentage of these errors to <5% in the ward in 6 months.Weekly point prevalence surveys were used to measure medication error rates over a 12-week baseline period. Errors in route, frequency of dose and maximum dose accounted for >80% of all prescribing errors. The intervention was a poster reminder about the three most common errors linked to standards for prescribing pain medication. Barriers to change were identified through inductive thematic analysis of semistructured interviews with five ward doctors and two staff nurses.In the 6 weeks after intervention, our run chart showed a shift in maximum dose errors per patient, which fell from 75% to 26%. However, route and frequency errors remained high at >70% per patient. Most of these errors were due to use of abbreviations, and qualitative interviews revealed that senior doctors and nurses believed that these abbreviations were safe. We found some evidence from national guidelines to support these beliefs.Overall, the intervention was associated with decreased prevalence of patients without a maximum dose written on their prescription, but lack of space on drug prescriptions was identified as a key barrier to further improvement in both maximum dose and abbreviation errors.
Topics: Documentation; Drug Prescriptions; Hospitals; Humans; Inpatients; Medication Errors
PubMed: 34544692
DOI: 10.1136/bmjoq-2020-001277 -
Nursing Outlook 2011This article looks at the effect of using fragmentary language in nursing documentation. Fragmentary language is defined as phrases and abbreviations found in records of...
This article looks at the effect of using fragmentary language in nursing documentation. Fragmentary language is defined as phrases and abbreviations found in records of nursing care that are understood at the local ward level but would make it difficult for anyone reading the documentation beyond this local level to construct meaning. Sixty-seven entries of nursing documentation were investigated using textual analysis. Each entry was examined to determine how grammatical and linguistic features of the text could impede meaning. Three entries are discussed in detail to demonstrate possible difficulty for readers in understanding the patient's condition and care. Education programs that encourage nurses to view their documentation as a crucial aspect of care are recommended. Writing nursing documentation in a manner that allows readers from both within and outside the profession to understand the patient's condition and care required is supported. If readers cannot understand what is written in nursing documentation, there is a danger that misinterpretations could lead to clinical errors and adverse events.
Topics: Documentation; Humans; Language; Nursing Records; Semantics; Writing
PubMed: 21684562
DOI: 10.1016/j.outlook.2011.04.002