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Health record documentation

Magdalena M Sakowska, Megan V Thomas, Saxon Connor, Ross Roberts
BACKGROUND: In measuring quality of health-care delivery, digital infrastructure is essential. The aim at this tertiary centre was to create a hospital-wide workflow system that collected data prospectively as part of daily practice. METHODS: In moving towards an electronic health record, a hospital-wide integrated workflow system was introduced in 2013, which electronically managed the perioperative patient journey while simultaneously facilitating surgical audit...
October 21, 2016: ANZ Journal of Surgery
Gregory P Beehler, Paul R King, Christina L Vair, Julie Gass, Jennifer S Funderburk
The VA has integrated psychologists and other licensed mental health providers, known collectively as co-located collaborative care (CCC) providers, into patients' primary care medical homes to improve mental health services for veterans. However, it is unclear if CCC providers are routinely using mental health measures as part of evidence-based, coordinated care. This study aimed to determine the prevalence and predictors of CCC provider utilization of brief, validated measures. A retrospective review of VA electronic medical records from 8403 veterans diagnosed with depression, posttraumatic stress disorder, or anxiety disorder was conducted...
October 21, 2016: Journal of Clinical Psychology in Medical Settings
J L NDiaye, B Cissé, E H Ba, J F Gomis, C T Ndour, J F Molez, F B Fall, C Sokhna, B Faye, E Kouevijdin, F K Niane, M Cairns, J F Trape, C Rogier, O Gaye, B M Greenwood, P J M Milligan
BACKGROUND: It is recommended that children aged 3 months to five years of age living in areas of seasonal transmission in the sub-Sahel should receive Seasonal Malaria Chemoprevention (SMC) with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ) during the malaria transmission season. The purpose of this study was to evaluate the safety of SMC with SPAQ in children when delivered by community health workers in three districts in Senegal where SMC was introduced over three years, in children from 3 months of age to five years of age in the first year, then in children up to 10 years of age...
2016: PloS One
Christopher Rowe, Eric Vittinghoff, Glenn-Milo Santos, Emily Behar, Caitlin Turner, Phillip Coffin
OBJECTIVES: Opioid overdose mortality has tripled in the USA since 2000 and opioids are responsible for more than half of all drug overdose deaths, which reached an all-time high in 2014. Opioid overdoses resulting in death, however, represent only a small fraction of all opioid overdose events and efforts to improve surveillance of this public health problem should include tracking nonfatal overdose events. International Classification of Disease (ICD) diagnosis codes, increasingly used for the surveillance of nonfatal drug overdose events, have not been rigorously assessed for validity in capturing overdose events...
October 20, 2016: Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
H Borgmann, M Rodríguez Socarrás, J Salem, I Tsaur, J Gomez Rivas, E Barret, L Tortolero
PURPOSE: To assess the feasibility, safety and usefulness of augmented reality-assisted urological surgery using smartglass (SG). METHODS: Seven urological surgeons (3 board urologists and 4 urology residents) performed augmented reality-assisted urological surgery using SG for 10 different types of operations and a total of 31 urological operations. Feasibility was assessed using technical metadata (number of photographs taken/number of videos recorded/video time recorded) and structured interviews with the urologists on their use of SG...
October 19, 2016: World Journal of Urology
Abebe Megerso, Sileshi Garoma
BACKGROUND: Antiretroviral treatment (ART) service scaling up has been practiced in the Ethiopia since 2006. Regardless of increasing number of primary health care centers providing the service, the existing hospitals are still overcrowded with ART service seeking patients may be because of the common belief that treatment outcome is better for hospital patients than those treated at the primary health centers. However, documented evidence comparing the treatment outcome for the two categories of health facilities is scarce in the study setting...
October 18, 2016: BMC Health Services Research
Luis I Rodriquez, Todd J Smaka, Michael Mahla, Richard H Epstein
BACKGROUND: In the United States, anesthesia information management systems (AIMS) are well established, especially within academic practices. Many hospitals are replacing their stand-alone AIMS during migration to an enterprise-wide electronic health record. This presents an opportunity to review choices made during the original implementation, based on actual usage. One area amenable to this informatics approach is the configuration in the AIMS of quick buttons for typical drug doses...
October 11, 2016: Anesthesia and Analgesia
Ivonne Orejel, Martin Castellanos, Diana Marín, Alberto Mendoza, Anthony D Harries
This study documented the number and results of mycobacterial culture and drug sensitivity testing (CDST) in Mexico from 2009-2013 and assessed whether states with a higher risk of multidrug-resistant tuberculosis (MDR-TB) performed more CDST and had more cultures showing MDR-TB. Data for this longitudinal, descriptive, operational research study came from the electronic records of 31 state public health laboratories in Mexico. The total number of CDSTs was 6 470, increasing from 2 143 in the first 2 years to 4 327 in the latter 3 years...
January 2016: Revista Panamericana de Salud Pública, Pan American Journal of Public Health
A Rumshisky, M Ghassemi, T Naumann, P Szolovits, V M Castro, T H McCoy, R H Perlis
The ability to predict psychiatric readmission would facilitate the development of interventions to reduce this risk, a major driver of psychiatric health-care costs. The symptoms or characteristics of illness course necessary to develop reliable predictors are not available in coded billing data, but may be present in narrative electronic health record (EHR) discharge summaries. We identified a cohort of individuals admitted to a psychiatric inpatient unit between 1994 and 2012 with a principal diagnosis of major depressive disorder, and extracted inpatient psychiatric discharge narrative notes...
October 18, 2016: Translational Psychiatry
Jonathan Richardson, Joe McDonald
The move to a digital health service may improve some components of health systems: information, communication and documentation of care. This article gives a brief definition and history of what is meant by an electronic health record (EHR). There is some evidence of benefits in a number of areas, including legibility, accuracy and the secondary use of information, but there is a need for further research, which may need to use different methodologies to analyse the impact an EHR has on patients, professionals and providers...
October 2016: BJPsych Bulletin
Joel Scholten, Ellen Danford, Azadeh Leland, Heather Malecki, Douglas Bidelspach, Brent Taylor, Nina Sayer
PURPOSE OF STUDY: Individualized interdisciplinary care is the hallmark for rehabilitation following traumatic brain injury (TBI). Veterans Health Administration (VHA) utilizes an electronic note template to document Interdisciplinary Rehabilitation and Community Reintegration (IRCR) care plans for Veterans with TBI requiring rehabilitation. All Veterans with a TBI diagnosis, receiving skilled therapy for TBI-related issues, and followed by a case manager must receive a care plan. The purpose of this study was to determine the level of compliance with the IRCR care plan requirements used to identify Veterans with TBI in need of the care plan and to evaluate the reasons for inconsistent compliance...
November 2016: Professional Case Management
Pawel Zagozdzon, Bartosz Goyke, Magdalena Wrotkowska
BACKGROUND: The role of antipsychotics in influencing mortality of patients with mental disorders is still unexplained. OBJECTIVE: The aim of this study was to determine mortality rates of patients treated with atypical and typical antipsychotics and to compare these data with the mortality rates for the general population. METHODS: The study was based on the 2008-2012 prescription drug reimbursement data from the Polish National Health Fund in Gdansk and mortality data from the death registry...
September 2016: Drugs—Real World Outcomes
Jennifer Jao, Rohan Hazra, Claude A Mellins, Robert H Remien, Elaine J Abrams
INTRODUCTION: The tremendous success of antiretroviral therapy has resulted in a diminishing population of perinatally HIV-infected children on the one hand and a mounting number of HIV-exposed uninfected (HEU) children on the other. As the oldest of these HEU children are reaching adolescence, questions have emerged surrounding the implications of HEU status disclosure to these adolescents. This article outlines the arguments for and against disclosure of a child's HEU status. DISCUSSION: Disclosure of a child's HEU status, by definition, requires disclosure of maternal HIV status...
2016: Journal of the International AIDS Society
Urooj Quezon Amjad, Jeanne Luh, Rachel Baum, Jamie Bartram
First developed by the World Health Organization, and now used in several countries, water safety plans (WSPs) are a multi-step, preventive process for managing drinking water hazards. While the beneficial impacts of WSPs have been documented in diverse countries, how to successfully implement WSPs in the United States remains a challenge. We examine the willingness and ability of water utility leaders to implement WSPs in the US state of North Carolina. Our findings show that water utilities have more of a reactive than preventive organizational culture, that implementation requires prioritization of time and resources, perceived comparative advantage to other hazard management plans, leadership in implementation, and identification of how WSPs can be embedded in existing work practices...
October 2016: Journal of Water and Health
Deepak Dimri, Venkatashiva Reddy B, Amit Kumar Singh
Background. The pattern of skin morbidity in an area depends on climate, geography, socioeconomic status, nutrition, genetics, and habits of the community. Objective. The objective of the present study was to describe the morbidity profile of patients attending dermatology outpatient department in a tertiary care centre of Garhwal hills, North India. Methodology. This is a record based study carried out using the morbidity registers. Patient details, diagnosis, and treatment provided by physicians were documented in the morbidity register...
2016: Dermatology Research and Practice
Roque da Silva Araújo, Edna Apparecida Moura Arcuri, Victor Cauê Lopes
Objective: to verify causes of inactivity in the Home Delivery Medicament Program, as referred by users from a Primary Health Care Service in São Paulo, comparing them to the causes registered in the program and analyzing them in the theoretical model Concept of Access to Health. Methods: cross-sectional study, interviewing 111 inactive users; and documentary study in the program records. Results: half of the users did not know the condition of inactivity...
October 10, 2016: Revista Latino-americana de Enfermagem
(no author information available yet)
BACKGROUND: Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time...
October 8, 2016: Lancet
Ken Nash, Frank Ghinassi, Jaspreet S Brar, Abdulkader Alam, Mary Catherine Bohan, Kalyani Gopalan, Amie Carter, K N Roy Chengappa
OBJECTIVES: 1. A quality performance improvement (QI) project to implement an electronic screening and monitoring tool to record components of the metabolic syndrome (e-MSD) during clinic visits by persons with serious mental illness (SMI). 2. To encourage psychiatrists to use this tool in their documentation. METHODS: Working with the information technology staff, five psychiatrists developed, tested, revised and embedded the e-MSD tool into the medication management document within the electronic health record...
2016: Clinical Schizophrenia & related Psychoses
Steve G Langer
In 1999-2003, SIIM (then SCAR) sponsored the creation of several special topic Primers, one of which was concerned with computer security. About the same time, a multi-society collaboration authored an ACR Guideline with a similar plot; the latter has recently been updated. The motivation for these efforts was the launch of Health Information Portability and Accountability Act (HIPAA). That legislation directed care providers to enable the portability of patient medical records across authorized medical centers, while simultaneously protecting patient confidentiality among unauthorized agents...
October 11, 2016: Journal of Digital Imaging: the Official Journal of the Society for Computer Applications in Radiology
Joshua R Ehrlich, Monica Michelotti, Taylor S Blachley, Kai Zheng, Mick P Couper, Grant M Greenberg, Sharon Kileny, Greta L Branford, David A Hanauer, Jennifer S Weizer
OBJECTIVES: To understand the attitudes and perceptions of ophthalmologists toward an electronic health record (EHR) system, before and after its clinical implementation. METHODS: Ophthalmologists at a single large academic ophthalmology department were surveyed longitudinally before and after implementation of a new EHR system. The survey measured ophthalmologists' attitudes toward implementation of a new EHR. Questions focused on satisfaction, efficiency, and documentation...
October 12, 2016: Applied Clinical Informatics
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