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Journal of the American Medical... Aug 2019Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the...
OBJECTIVES
Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission.
DESIGN
Retrospective study using 2 abstractors blinded to the study aims.
SETTING AND PARTICIPANTS
474 records from NH residents transferred to the 3 EDs of Rhode Island's largest health care system from September 2015 to September 2016.
MEASURES
NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission.
RESULTS
Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P = .03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01-1.18).
CONCLUSIONS/IMPLICATIONS
Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms.
Topics: Aged; Aged, 80 and over; Dementia; Documentation; Electronic Health Records; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Nursing Homes; Patient Transfer; Retrospective Studies; Rhode Island
PubMed: 30385229
DOI: 10.1016/j.jamda.2018.09.008 -
Journal of General Internal Medicine Feb 2022Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the...
BACKGROUND
Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability.
OBJECTIVE
Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool.
DESIGN, PARTICIPANTS, AND MAIN MEASURES
The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting.
KEY RESULTS
The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality.
CONCLUSIONS
The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
Topics: Clinical Competence; Clinical Reasoning; Documentation; Feedback; Humans; Models, Psychological; Reproducibility of Results
PubMed: 33945113
DOI: 10.1007/s11606-021-06805-6 -
Bioinformatics (Oxford, England) Oct 2023Pangenomes are replacing single reference genomes as the definitive representation of DNA sequence within a species or clade. Pangenome analysis predominantly leverages...
SUMMARY
Pangenomes are replacing single reference genomes as the definitive representation of DNA sequence within a species or clade. Pangenome analysis predominantly leverages graph-based methods that require computationally intensive multiple genome alignments, do not scale to highly complex eukaryotic genomes, limit their scope to identifying structural variants (SVs), or incur bias by relying on a reference genome. Here, we present PanKmer, a toolkit designed for reference-free analysis of pangenome datasets consisting of dozens to thousands of individual genomes. PanKmer decomposes a set of input genomes into a table of observed k-mers and their presence-absence values in each genome. These are stored in an efficient k-mer index data format that encodes SNPs, INDELs, and SVs. It also includes functions for downstream analysis of the k-mer index, such as calculating sequence similarity statistics between individuals at whole-genome or local scales. For example, k-mers can be "anchored" in any individual genome to quantify sequence variability or conservation at a specific locus. This facilitates workflows with various biological applications, e.g. identifying cases of hybridization between plant species. PanKmer provides researchers with a valuable and convenient means to explore the full scope of genetic variation in a population, without reference bias.
AVAILABILITY AND IMPLEMENTATION
PanKmer is implemented as a Python package with components written in Rust, released under a BSD license. The source code is available from the Python Package Index (PyPI) at https://pypi.org/project/pankmer/ as well as Gitlab at https://gitlab.com/salk-tm/pankmer. Full documentation is available at https://salk-tm.gitlab.io/pankmer/.
Topics: Humans; Genome; Software; Eukaryota; Documentation; Sequence Analysis, DNA
PubMed: 37846049
DOI: 10.1093/bioinformatics/btad621 -
Applied Clinical Informatics 2014To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors...
OBJECTIVE
To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases.
METHODS
Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods.
RESULTS
A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001).
DISCUSSION
There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists.
CONCLUSION
As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.
Topics: Academic Medical Centers; Chronic Disease; Coronary Artery Disease; Diabetes Mellitus; Documentation; Electronic Health Records; Humans; Patient Care; Physicians, Primary Care; Quality of Health Care; Retrospective Studies
PubMed: 25024762
DOI: 10.4338/ACI-2014-01-RA-0007 -
The Nursing Clinics of North America Jun 1988Public health nurses reminisce about the days when writing about the care given was a small part of the workday. Third parties certainly were not as interested in what...
Public health nurses reminisce about the days when writing about the care given was a small part of the workday. Third parties certainly were not as interested in what was documented then as they are today. Perhaps the state would admonish an agency about the fact that goals were missing in the charts, but no one talked about documentation being the key to reimbursement and agency survival. Needless to say, times have changed. Public health nurses are suffering these days because they are not only laboring to provide care to a group of patients who are older and sicker than they were in the past, but they are spending more hours each day writing about what they have seen and done. These nurses are haunted by the fear that they might omit a vital piece of information which would jeopardize both their licenses and reimbursement. New forms initiated by the federal government to improve screening for nonreimbursable care have been successful. They have helped to increase denials as well as the volume of paperwork necessary for writing up a Medicare case. Consequently, nurses are frustrated. Although they are writing more, the outcome is negative. Documentation is an essential part of care. It is a vehicle for communicating from one professional to another about the status and needs of the patient. In fact, the chart is often the only means to demonstrate that professional standards, state regulations, and the criteria for reimbursement were met. However, to the extent that charting significantly interferes with the amount of time nurses can spend with patients, it must be limited.(ABSTRACT TRUNCATED AT 250 WORDS)
Topics: Administrative Personnel; Documentation; Home Care Services; Humans; Nurse Administrators; Public Health Nursing; United States
PubMed: 3368397
DOI: No ID Found -
Acta Chirurgiae Orthopaedicae Et... 2017Conventional documentation of surgical procedures using only pre- and postoperative X-ray images and possibly a few intra-operative pictures does not allow secondary...
Conventional documentation of surgical procedures using only pre- and postoperative X-ray images and possibly a few intra-operative pictures does not allow secondary analysis of the technical performance in detail. In particular, the quality of the handling of tissues and surgical tools cannot be judged «post hoc», i.e. after the end of the surgical procedure. The invasiveness of the surgical act cannot yet be quantified. Surrogate invasiveness indices have therefore been developed. Furthermore, conventional documentation does not allow evaluation of the proper use of the C-arm both technically and with regard to fluoroscopy time. Documentation that follows the ICUC® documentation concept includes all fluoroscopy shots and images covering all key portions of the entire surgical procedure by multiple still images or videos. In certain cases, such documentation can help to explain post-operative courses that might be difficult to understand based only on X-rays and written operation reports. Finally, the data included in ICUC® documentation are a valuable source for knowledge extraction. In addition, time saving is conceivable if operation reports can include images of the key stages of the procedure with a few additional comments dictated during the surgery. Key words: trauma surgery, ICUC® documentation concept.
Topics: Documentation; Fluoroscopy; Humans; Surgical Procedures, Operative; Wounds and Injuries
PubMed: 28809633
DOI: No ID Found -
Journal of Health Psychology Jan 2022This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic...
This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic health records. We propose specific hypotheses about how features of clinicians' written notes might trigger mechanisms of placebo and nocebo effects to elicit positive or adverse health effects among patients. Bridging placebo studies with (a) survey data assaying patient and clinician experiences with portals and (b) randomized controlled trials provides preliminary support for our hypotheses. We conclude with actionable proposals for testing our understanding of the health effects of access to visit notes.
Topics: Documentation; Electronic Health Records; Humans; Nocebo Effect; Surveys and Questionnaires
PubMed: 32772861
DOI: 10.1177/1359105320948588 -
BMJ Open Quality Nov 2022The purpose of this quality improvement project was to improve the rate of pregnancy counselling and documentation regarding the risk of being on teratogenic...
The purpose of this quality improvement project was to improve the rate of pregnancy counselling and documentation regarding the risk of being on teratogenic medications, including leflunomide, mycophenolate, methotrexate or cyclophosphamide in women of childbearing age (17-50 years). Our goal was to increase documentation rates by 25% in 6 months. We first performed an EMR chart review of 103 women who were seen in the 6 months prior to intervention by faculty at a single rheumatology academic centre. We then determined how many of those women had documented contraception or pregnancy counselling, which included written documentation anywhere in the note or ICD codes which were specific to pregnancy counselling or contraception counselling. Interventions were then implemented. The percentage of women who had documented pregnancy counselling did not change preintervention and postintervention; preintervention 37% of women received documented pregnancy counselling and postintervention 35% of women received documented pregnancy counselling. The percentage of women who had documented contraception counselling did however change preintervention and postintervention; preintervention 37% of women received documented contraception counselling and postintervention 51% of women received documented contraception counselling, which is a 14% improvement.
Topics: Pregnancy; Female; Humans; Adolescent; Young Adult; Adult; Middle Aged; Quality Improvement; Rheumatology; Contraception; Counseling; Documentation
PubMed: 36332937
DOI: 10.1136/bmjoq-2022-001871 -
BMJ Open Quality Oct 2021Most women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already...
BACKGROUND
Most women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already decided about future mode of birth (FMOB) before a subsequent pregnancy. Hence, providing women with LAC counselling soon after birth may help women plan for future pregnancies. Prior to our intervention, our hospital had no method of ensuring that women received LAC counselling after caesarean section. The purpose of this QI initiative was to assess whether formal LAC documentation on labour and delivery (L&D) improves rates of LAC counselling post partum.
METHODS
Our three-part intervention included: (1) surgeon's assessment of LAC feasibility in the operative note, (2) written LAC education for women in discharge paperwork and (3) documentation of LAC counselling in the discharge summary. We implemented these changes on L&D in January 2019. We conducted phone surveys of 40 women after caesarean preintervention and postintervention. Surveys included questions regarding three primary outcomes: whether or not they had received LAC counselling either in the hospital or at a postpartum visit, and whether or not they would pursue LAC as FMOB. Surveys also assessed two secondary outcomes: (1) women's understanding of the indications for surgery and (2) their involvement in the decision process. We used a χ analysis to assess primary outcomes and a Fisher's exact test to assess secondary outcomes. We also surveyed providers about the culture of LAC counselling at our hospital.
RESULTS
After our intervention, there was a significant difference between the number of women reporting LAC postpartum counselling (30.77% vs 53.8%, p=0.04). There was also a significant difference in the number of women feeling involved in the decision-making process (68% vs 95%, p=0.03). Providers reported improved knowledge/confidence around LAC counselling (58%-100%). Providers universally stated that LAC counselling has become more ingrained in the culture on L&D.
CONCLUSIONS
Documentation of LAC counselling improved the consistency with which providers incorporated LAC counselling into postpartum care. Addressing FMOB at the time of pLTCS and documenting that counselling may be an effective first step in empowering women to pursue LAC in future pregnancies.
Topics: Cesarean Section; Counseling; Documentation; Female; Humans; Pregnancy; Quality Improvement
PubMed: 34716182
DOI: 10.1136/bmjoq-2020-001232 -
International Journal of Mental Health... Aug 2022The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of... (Observational Study)
Observational Study
The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information-sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision-making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision-making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias.
Topics: Cognition; Documentation; Humans; Inpatients; Nursing Care; Surveys and Questionnaires
PubMed: 35355387
DOI: 10.1111/inm.12997