keyword
MENU ▼
Read by QxMD icon Read
search

Clinical documentation

keyword
https://www.readbyqxmd.com/read/28335058/instructions-for-radiological-case-reports
#1
Peter Bannas
Purpose This paper explains the purpose and structure of a radiological case report and provides guidance for radiologists with respect to the writing of a well-structured patient case report. Materials and Methods The current literature and the author's experience as a writer were used to create a manual that describes steps for preparing a radiological case report containing all of the important ingredients for effective communication. Results Case reports are the first line of evidence in documenting clinical observations in the literature...
April 2017: RöFo: Fortschritte Auf Dem Gebiete der Röntgenstrahlen und der Nuklearmedizin
https://www.readbyqxmd.com/read/28334802/engagement-strategies-that-foster-community-self-determination-in-participatory-research-insider-ownership-through-outsider-championship
#2
Jon Salsberg, Soultana Macridis, Enrique Garcia Bengoechea, Ann C Macaulay, Spencer Moore
Background.: In order to maximize the benefits of community-based participatory research, effective ownership over the research process must be at least equally in the hands of the community. A previous social network analysis documented that the participatory research process shifted ownership from academic to community partners, but did not show what actions and strategies fostered this shift. Objectives.: This study follows the trajectory of a community-academic partnership and asks, from the perspective of the project stakeholders, which actions and strategies over the lifespan of the research led to the observed shift in ownership and decision-making from the original external academics to the community stakeholders? Methods...
February 18, 2017: Family Practice
https://www.readbyqxmd.com/read/28334772/transparency-policies-of-the-european-medicines-agency-has-the-paradigm-shifted
#3
Daria Kim
This article reflects on the state of play as regards access to non-summary clinical trial data in the European Union (EU). In particular, it examines the scope of access under the recent transparency policies of the European Medicines Agency (EMA) that attempt to break away from the presumptively confidential treatment of clinical trial data. In light of the emerging case law of the Court of Justice of the European Union on clinical trial data disclosure, it remains highly uncertain what data, and under what conditions, can be lawfully released by the EMA...
February 23, 2017: Medical Law Review
https://www.readbyqxmd.com/read/28334592/using-an-electronic-perioperative-documentation-tool-to-identify-returns-to-operating-room-ror-in-a-tertiary-care-academic-medical-center
#4
Robert R Cima, Sarah R Dhanorker, Christopher L Ostendorf, Mfonabasi Ntekpe, Raghu V Mudundi, Elizabeth B Habermann, Claude Deschamps
BACKGROUND: The metric "Unplanned returns to operating room (ROR)" is being tracked in surgical quality dashboards; 70% of unplanned RORs may be related to surgical complications. With increasing regionalization of trauma and complex surgical care at tertiary care academic centers, it is unclear if a simple ROR metric is a valid assessment of surgical quality at such centers. METHOD: A real-time electronic tool was used to identify all RORs-planned and unplanned-in a high-volume, high-complexity academic surgical practice at Mayo Clinic-Rochester within 45 days of the index operation...
March 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28334591/crossing-the-communication-chasm-challenges-and-opportunities-in-transitions-of-care-from-the-hospital-to-the-primary-care-clinic
#5
Nicholas A Rattray, Jason J Sico, LeeAnn M Cox, Alissa L Russ, Marianne S Matthias, Richard M Frankel
BACKGROUND: Transitions of care from specialty and acute settings to primary care abound. Compared to the continuity in end-of-shift handoffs, care transitions involve provider communication between practices and facilities with their own cultures and bureaucracies. Using the transition from acute care to outpatient primary care for stroke/transient ischemic attack (TIA) patients as a case study, this qualitative research explored communication practices and institutional arrangements among clinical providers responsible for longitudinal management of hypertension...
March 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28334564/data-driven-implementation-of-alarm-reduction-interventions-in-a-cardiovascular-surgical-icu
#6
Sharon H Allan, Peter A Doyle, Adam Sapirstein, Maria Cvach
BACKGROUND: Alarm fatigue in the ICU setting has been well documented in the literature. The ICU's high-intensity environment requires staff's vigilant attention, and distraction from false and non-actionable alarms pulls staff away from important tasks, creates dissatisfaction, and is a potential patient safety risk if alarms are missed or ignored. This project was intended to improve patient safety by optimizing alarm systems in a cardiovascular surgical intensive care unit (CVSICU)...
February 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28334560/development-and-preliminary-testing-of-the-coordination-process-error-reporting-tool-cpert-a-prospective-clinical-surveillance-mechanism-for-teamwork-errors-in-the-pediatric-cardiac-icu
#7
Katherine E Bates, Judy A Shea, Geoffrey L Bird, Cynthia Field, Deipanjan Nandi, Robert E Shaddy, Joshua P Metlay
BACKGROUND: Patient safety reporting systems (PSRSs) may not detect teamwork or coordination process errors that affect all dimensions of quality defined by the Institute of Medicine. This study aimed to develop and observe the performance of a novel tool, the Coordination Process Error Reporting Tool (CPERT), as a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. METHODS: Providers and parents used the qualitative nominal group technique to identify coordination process error examples...
December 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28334496/seasonality-at-the-clinical-onset-of-type-1-diabetes-lessons-from-the-sweet-database
#8
A Gerasimidi Vazeou, O Kordonouri, M Witsch, J M Hermann, G Forsander, C de Beaufort, H J Veeze, C Maffeis, V Cherubini, O Cinek, B Piccini, R W Holl, T Danne
BACKGROUND: Seasonality at the clinical onset of type 1 diabetes (T1D) has been suggested by different studies, however, the results are conflicting. This study aimed to evaluate the presence of seasonality at clinical onset of T1D based on the SWEET database comprising data from 32 different countries. METHODS: The study cohort included 23 603 patients (52% males) recorded in the international multicenter SWEET database (48 centers), with T1D onset ≤20 years, year of onset between 1980 and 2015, gender, year and month of birth and T1D-diagnosis documented...
October 2016: Pediatric Diabetes
https://www.readbyqxmd.com/read/28334471/the-clinical-applicability-of-a-daily-summary-of-patients-self-reported-postoperative-pain-a-repeated-measure-analysis
#9
Lotta Wikström, Kerstin Eriksson, Bengt Fridlund, Mats Nilsson, Kristofer Årestedt, Anders Broström
AIM AND OBJECTIVES: (I) to determine if a central tendency, median, based on patients' self-rated pain is a clinically applicable daily measure to show patients' postoperative pain on the first day after major surgery (II) and to determine the number of self-ratings required for the calculation of this measure. BACKGROUND: Perioperative pain traits in medical records are difficult to overview. The clinical applicability of a daily documented summarising measure of patients' self-rated pain scores is little explored...
March 23, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/28334309/long-term-surveillance-following-intralesional-steroid-injection-for-benign-vocal-fold-lesions
#10
Chi-Te Wang, Mei-Shu Lai, Po-Wen Cheng
Importance: The short-term outcomes of vocal fold steroid injection (VFSI) are well documented. However, few studies have reported the long-term outcomes following VFSI. Objective: To investigate the incidence rates of symptom recurrence and secondary interventions following VFSI for benign vocal fold lesions. Design, Setting, and Participants: This prospective cohort study was conducted at a tertiary referral medical center in Taipei, Taiwan...
March 23, 2017: JAMA Otolaryngology—Head & Neck Surgery
https://www.readbyqxmd.com/read/28333942/comparison-of-self-measured-diurnal-intraocular-pressure-profiles-using-rebound-tonometry-between-primary-angle-closure-glaucoma-and-primary-open-angle-glaucoma-patients
#11
Shaoying Tan, Nafees Baig, Linda Hansapinyo, Vishal Jhanji, Shihui Wei, Clement C Tham
PURPOSE: To document the diurnal intraocular pressure (IOP) profile with rebound tonometry performed by primary glaucoma patients in non-clinic environment. PATIENTS AND METHODS: Fifty-three medically-treated eyes of 31 primary angle closure glaucoma (PACG) and 22 primary open angle glaucoma (POAG) patients with no previous eye surgery were recruited. Diurnal IOP was measured 5 times per day at four-hourly intervals from 08:00 to 24:00 for 1 week in patients' study eye using rebound tonometry in a non-clinic environment...
2017: PloS One
https://www.readbyqxmd.com/read/28333850/multimodality-ocular-imaging-in-a-case-report-of-hyperviscosity-syndrome-associated-with-lymphoplasmacytic-leukemia-the-images-tell-the-story
#12
Rene Y Choi, Rachel Jacoby, Akbar Shakoor
PURPOSE: To report the clinical course of a patient with ocular manifestations of hyperviscosity syndrome associated with Waldenström macroglobulinemia, and for the first time, video imaging of mobile emboli in the conjunctival and retinal vasculature. METHODS AND PATIENT: A 60-year-old woman with newly diagnosed Waldenström macroglobulinemia, with no visual complaints was evaluated by the Ophthalmology service for a baseline ocular examination. RESULTS: At presentation, ocular examination revealed a visual acuity of 20/25 in each eye...
March 22, 2017: Retinal Cases & Brief Reports
https://www.readbyqxmd.com/read/28333788/nursing-interruptions-in-a-trauma-intensive-care-unit-a-prospective-observational-study
#13
Nicole C Craker, Robert A Myers, Jessy Eid, Priti Parikh, Mary C McCarthy, Kathy Zink, Pratik J Parikh
OBJECTIVE: The aims of this study were to identify and analyze elements that affect duration of an interruption and likelihood of activity switch as experienced by nurses in an ICU. BACKGROUND: Although interruptions in the ICU impact patient safety, little is known regarding the complex situations that drive them. METHODS: RNs were observed in a 23-bed surgical ICU. We observed 206 interruptions, and analyzed for duration and activity switch...
April 2017: Journal of Nursing Administration
https://www.readbyqxmd.com/read/28333706/video-based-physiologic-monitoring-during-an-acute-hypoxic-challenge-heart-rate-respiratory-rate-and-oxygen-saturation
#14
Paul S Addison, Dominique Jacquel, David M H Foo, André Antunes, Ulf R Borg
BACKGROUND: The physiologic information contained in the video photoplethysmogram is well documented. However, extracting this information during challenging conditions requires new analysis techniques to capture and process the video image streams to extract clinically useful physiologic parameters. We hypothesized that heart rate, respiratory rate, and oxygen saturation trending can be evaluated accurately from video information during acute hypoxia. METHOD: Video footage was acquired from multiple desaturation episodes during a porcine model of acute hypoxia using a standard visible light camera...
March 22, 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/28333597/when-is-parenteral-nutrition-appropriate
#15
Patricia Worthington, Jane Balint, Matthew Bechtold, Angela Bingham, Lingtak-Neander Chan, Sharon Durfee, Andrea K Jevenn, Ainsley Malone, Maria Mascarenhas, Daniel T Robinson, Beverly Holcombe
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use...
March 2017: JPEN. Journal of Parenteral and Enteral Nutrition
https://www.readbyqxmd.com/read/28333318/a-phase-iii-randomized-controlled-trial-comparing-the-efficacy-safety-and-tolerability-of-oral-dydrogesterone-versus-micronized-vaginal-progesterone-for-luteal-support-in-in-vitro-fertilization
#16
Herman Tournaye, Gennady T Sukhikh, Elke Kahler, Georg Griesinger
STUDY QUESTION: Is oral dydrogesterone 30 mg daily (10 mg three times daily [TID]) non-inferior to micronized vaginal progesterone (MVP) 600 mg daily (200 mg TID) for luteal support in in vitro fertilization (IVF), assessed by the presence of fetal heartbeats determined by transvaginal ultrasound at 12 weeks of gestation? SUMMARY ANSWER: Non-inferiority of oral dydrogesterone versus MVP was demonstrated at 12 weeks of gestation, with a difference in pregnancy rate and an associated confidence interval (CI) that were both within the non-inferiority margin...
March 1, 2017: Human Reproduction
https://www.readbyqxmd.com/read/28333157/consensus-approach-to-nasal-high-flow-therapy-in-neonates
#17
B A Yoder, B Manley, C Collins, K Ives, A Kugelman, A Lavizzari, M McQueen
OBJECTIVE: Nasal high-flow therapy (nHFT) is commonly used for noninvasive respiratory support in the neonatal intensive care unit. Our objective was to determine which aspects of neonatal nHFT have achieved adequate evidence base to support consensus among experienced clinical investigators, and to document areas lacking consensus to promote future investigations. STUDY DESIGN: Prospective, modified Delphi collation of tabular queries related to specific aspects of neonatal nHFT...
March 23, 2017: Journal of Perinatology: Official Journal of the California Perinatal Association
https://www.readbyqxmd.com/read/28332925/implications-of-clinical-documentation-in-accuracy-a-pilot-study-among-general-surgery-residents
#18
Andrea Garcia, Lee Revere, Sherene Sharath, Panos Kougias
Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is essential to assuring accurate and reliable medical records. Yet, prior literature reveals surgery residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because the evaluation of and reimbursement for healthcare service delivery relies on the physician's ability to produce appropriate medical records, which then get translated into billable codes...
March 23, 2017: Hospital Topics
https://www.readbyqxmd.com/read/28332132/redefining-the-role-of-biomarkers-in-heart-failure-trials-expert-consensus-document
#19
REVIEW
Frank Kramer, Hani N Sabbah, James J Januzzi, Faiez Zannad, J Peter van Tintelen, Erik B Schelbert, Raymond J Kim, Hendrik Milting, Richardus Vonk, Brien Neudeck, Richard Clark, Klaus Witte, Wilfried Dinh, Burkert Pieske, Javed Butler, Mihai Gheorghiade
Heart failure is a growing cardiovascular disease with significant epidemiological, clinical, and societal implications and represents a high unmet need. Strong efforts are currently underway by academic and industrial researchers to develop novel treatments for heart failure. Biomarkers play an important role in patient selection and monitoring in drug trials and in clinical management. The present review gives an overview of the role of available molecular, imaging, and device-derived digital biomarkers in heart failure drug development and highlights capabilities and limitations of biomarker use in this context...
March 23, 2017: Heart Failure Reviews
https://www.readbyqxmd.com/read/28331764/how-many-of-the-biopsy-decisions-taken-at-inexperienced-breast-radiology-units-were-correct
#20
Özlem Demircioğlu, Meral Uluer, Erkin Arıbal
OBJECTIVE: In this study, we aimed to determine the need for biopsy in patients referred from other clinics for the performance of biopsy with the suspicion of breast cancer. MATERIALS AND METHODS: 112 patients were included in the study. It was decided that their biopsies be performed following examinations in other clinics and they presented to the breast radiology unit of our hospital for a second opinion. The demographic characteristics, diagnostic studies completed in the other centers, properties of lesions, decision made as a result of examinations and BI-RADS (Breast Imaging Reporting and Data Systems) categorizations were recorded on the registration forms of the study patients...
January 2017: J Breast Health (2013)
keyword
keyword
30211
1
2
Fetch more papers »
Fetching more papers... Fetching...
Read by QxMD. Sign in or create an account to discover new knowledge that matter to you.
Remove bar
Read by QxMD icon Read
×

Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"