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Journal of Patient Safety Dec 2019The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to...
OBJECTIVE
The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians.
PATIENTS AND METHODS
This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out.
RESULTS
Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs.
CONCLUSIONS
Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.
Topics: Aged; Aged, 80 and over; Communication; Continuity of Patient Care; Delirium; Documentation; Drug-Related Side Effects and Adverse Reactions; Female; Health Status; Hospitalization; Humans; Male; Medical Records; Mental Health; Middle Aged; Physicians; Retrospective Studies; Writing
PubMed: 28098585
DOI: 10.1097/PTS.0000000000000280 -
Medical Education May 2009
Topics: Documentation; Education, Medical, Undergraduate; Educational Measurement; Humans; Illinois; Reproducibility of Results
PubMed: 19422504
DOI: 10.1111/j.1365-2923.2009.03330.x -
Ultraschall in Der Medizin (Stuttgart,... Dec 1992A system for documentation of ultrasonographic findings is presented. Characteristic items and features of a report are defined.
A system for documentation of ultrasonographic findings is presented. Characteristic items and features of a report are defined.
Topics: Cholelithiasis; Documentation; Humans; Medical Records, Problem-Oriented; Ultrasonography
PubMed: 1290090
DOI: 10.1055/s-2007-1005323 -
Der Radiologe Jul 2014The written radiological report is the most important means of communication between the radiologist and the referring medical doctor. There is no universal definition... (Review)
Review
The written radiological report is the most important means of communication between the radiologist and the referring medical doctor. There is no universal definition of a radiological report concerning its structure and content. The majority of clinicians and radiologists prefer structured reporting rather than free text reports of findings. Structured reporting does not increase the quality of a radiological report but has many advantages in research, teaching and quality management. Using standard RadLex terms facilitates translation and ontological assignment of a report. The Reporting Initiative of the Radiological Society of North America (RSNA) offers free and freely available extensively validated best practices radiology report templates in the new management of radiology report templates (MRRT) format according to the guidelines of the Integrating the Healthcare Enterprise (IHE).
Topics: Diagnostic Imaging; Documentation; Forms and Records Control; Germany; Health Records, Personal; Medical Records Systems, Computerized; Practice Guidelines as Topic; Radiology; Writing
PubMed: 24989877
DOI: 10.1007/s00117-014-2681-z -
Studies in Health Technology and... May 2023To explore the inter-rater reliability of the Swedish translation of NCP-QUEST in a Swedish context and investigate the level of agreement between Diet-NCP-Audit and...
To explore the inter-rater reliability of the Swedish translation of NCP-QUEST in a Swedish context and investigate the level of agreement between Diet-NCP-Audit and NCP-QUEST in assessment of documentation quality. A retrospective audit was conducted of 40 electronic patient records written by dietitians at one University Hospital in Sweden. NCP-QUEST showed good inter-rater reliability for the quality category (ICC = 0.85) and excellent inter-rater reliability for total score (ICC = 0.97).
Topics: Humans; Nutritionists; Retrospective Studies; Reproducibility of Results; Diet; Documentation
PubMed: 37203704
DOI: 10.3233/SHTI230159 -
Journal of Medical Internet Research Nov 2022Topic modeling approaches allow researchers to analyze and represent written texts. One of the commonly used approaches in psychology is latent Dirichlet allocation... (Review)
Review
BACKGROUND
Topic modeling approaches allow researchers to analyze and represent written texts. One of the commonly used approaches in psychology is latent Dirichlet allocation (LDA), which is used for rapidly synthesizing patterns of text within "big data," but outputs can be sensitive to decisions made during the analytic pipeline and may not be suitable for certain scenarios such as short texts, and we highlight resources for alternative approaches. This review focuses on the complex analytical practices specific to LDA, which existing practical guides for training LDA models have not addressed.
OBJECTIVE
This scoping review used key analytical steps (data selection, data preprocessing, and data analysis) as a framework to understand the methodological approaches being used in psychology research using LDA.
METHODS
A total of 4 psychology and health databases were searched. Studies were included if they used LDA to analyze written words and focused on a psychological construct or issue. The data charting processes were constructed and employed based on common data selection, preprocessing, and data analysis steps.
RESULTS
A total of 68 studies were included. These studies explored a range of research areas and mostly sourced their data from social media platforms. Although some studies reported on preprocessing and data analysis steps taken, most studies did not provide sufficient detail for reproducibility. Furthermore, the debate surrounding the necessity of certain preprocessing and data analysis steps is revealed.
CONCLUSIONS
Our findings highlight the growing use of LDA in psychological science. However, there is a need to improve analytical reporting standards and identify comprehensive and evidence-based best practice recommendations. To work toward this, we developed an LDA Preferred Reporting Checklist that will allow for consistent documentation of LDA analytic decisions and reproducible research outcomes.
Topics: Humans; Reproducibility of Results; Big Data; Documentation; Databases, Factual
PubMed: 36346659
DOI: 10.2196/33166 -
Journal of Clinical Nursing Aug 2018To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that...
AIMS AND OBJECTIVES
To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process.
BACKGROUND
The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122-1131).
DESIGN
The project was a mixed-method, two-phase study that collected data from two sites.
METHODS
In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice.
RESULTS
Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration.
CONCLUSIONS
We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation.
RELEVANCE TO CLINICAL PRACTICE
Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases.
Topics: Decision Making; Documentation; Electronic Health Records; Female; Humans; Male; Mental Disorders; Psychiatric Nursing; Psychotropic Drugs
PubMed: 29752835
DOI: 10.1111/jocn.14511 -
Journal of Surgical Education 2018To construct and pilot an educational tool to improve the quality of postoperative documentation at Mayo University Hospital.
OBJECTIVE
To construct and pilot an educational tool to improve the quality of postoperative documentation at Mayo University Hospital.
DESIGN
Retrospective data were collected from 100 consecutive patients treated surgically during October to November 2016. The first written ward based note following surgery was analyzed against RCS quality standards outlined in "Good Surgical Practice." An educational tool was then constructed to improve postoperative documentation. The mnemonic created was POST-OP-physiotherapy/mobilization, operative diagnosis, sepsis, thromboprophylaxis, oral intake/fluid balance, and pain. A second audit cycle involving 103 patients was carried out prospectively in March 2017.
SETTING
Mayo University Hospital, a 330 bed teaching hospital affiliated with the National University of Ireland, Galway.
PARTICIPANTS
All patients who had undergone either an elective or an emergency general surgery procedure over two 5-week periods.
RESULTS
Comparing the 2 study periods, significant improvements in the quality of postoperative surgical documentation was observed. All standards improved including patient identification (17.8% vs 78.1%, p < 0.001) and name of note maker (54.7% vs 86.2%, p < 0.001). There was also improvement in the documentation of antibiotic use (23.8% vs 75.8%, p > 0.001), thromboprophylaxis (7.1% vs 75.8%, p < 0.001), analgesia (36.9% vs 74.7%, p < 0.001), operative diagnosis (66.6% vs 91.9%, p < 0.001), and mobilization (23.6% vs 78.1%, p < 0.001) following the introduction of the POST-OP tool.
CONCLUSION
The design and introduction of the POST-OP education tool helped to significantly improve documentation and educate surgical residents on the essential components of postoperative care. The above data suggest that this effective mnemonic can improve the quality of postoperative documentation for surgical patients.
Topics: Documentation; Education, Medical, Graduate; General Surgery; Humans; Internship and Residency; Ireland; Pilot Projects; Postoperative Period; Practice Patterns, Physicians'; Program Development; Program Evaluation; Quality Improvement; Retrospective Studies; United States
PubMed: 29398629
DOI: 10.1016/j.jsurg.2018.01.005 -
Journal of Infusion Nursing : the... 2011Infusion therapy nurses can be successful in obtaining research funding by understanding and executing the important steps of effective grant writing. This article...
Infusion therapy nurses can be successful in obtaining research funding by understanding and executing the important steps of effective grant writing. This article provides information on and discussion about these essential steps to prepare successful applications: identifying funding options, recognizing the importance of writing time, implementing documentation on why research is needed, understanding the components of a research grant, implementing innovative ideas, and identifying characteristics of effectively written grants.
Topics: Documentation; Organizational Innovation; Private Sector; Research Support as Topic; Writing
PubMed: 21508720
DOI: 10.1097/NAN.0b013e31821130a6 -
Human Resources For Health Oct 2021During participation in Field Epidemiology Training Programs (FETP) residents/fellows generate scientific evidence from the various public health projects they are...
BACKGROUND
During participation in Field Epidemiology Training Programs (FETP) residents/fellows generate scientific evidence from the various public health projects they are engaged in. However, this evidence is not sufficiently disseminated to influence policy and practice. We describe the processes through which evidence is disseminated, and share achievements and lessons learnt during the first 5 years of the Uganda Public Health Fellowship Program (PHFP).
METHODS
The PHFP is a 2-year, full-time, non-degree fellowship, and the first post-masters FETP in Africa for mid-career public health professionals. Fellows gain competencies in seven main domains, which are demonstrated by deliverables while learning through service delivery, 80% of the time within Ministry of Health and related agencies. Generated public health evidence is disseminated immediately through sharing of daily situation reports with the National Task Force for Epidemic Preparedness and Response, as well as regional and district levels. Information is also disseminated on an intermediate to long-term basis through newspaper articles, epidemiological bulletins, abstracts and conference presentations, and publications in scientific journals.
RESULTS
During 2015-2020, PHFP enrolled 80 fellows in seven cohorts, including five of whom who had graduated. Overall, 355 field projects had been implemented. Additionally, PHFP made 287 conference presentations including 108 international and 178 national conferences. Altogether, the Uganda PHFP has received 7 awards, 4 of these for excellent scientific presentations during conferences. By end of 2020, PHFP had written 147 manuscripts at different stages of peer review, including 53 publications; and published 153 epidemiological bulletins. Dissemination performance was limited by delays due to challenges like non-adherence to product clearance guidelines, limited persons to conduct product review, and limited expertise on certain scientific areas, authorship related issues, and competing priorities among fellows, staff, and alumni.
CONCLUSIONS
The PHFP has disseminated public health evidences through various means to a wider range of audiences within Uganda and globally. Manuscript publication and monitoring of actions taken as a result of evidence dissemination is still limited. We recommend putting in place mechanisms to facilitate publication of all scientific evidence and deliberate efforts to ensure and monitor scientific evidence utilization.
Topics: Documentation; Epidemics; Fellowships and Scholarships; Humans; Public Health; Uganda
PubMed: 34674709
DOI: 10.1186/s12960-021-00665-1