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Health record documentation

Kade L Paterson, Christopher Harrison, Helena Britt, Rana S Hinman, Kim L Bennell
OBJECTIVE: To document the management of foot/ankle osteoarthritis/arthritis (OA) by general practitioners (GP) in Australia. DESIGN: We analysed data from the Bettering the Evaluation and Care of Health Program April 2010-March 2016 inclusive. Patient and GP encounter characteristics were extracted. Data were classified by the International Classification of Primary Care, Version 2, and summarised using descriptive statistics and 95% confidence intervals (95% CIs) around point estimates...
April 12, 2018: Osteoarthritis and Cartilage
Kayte Spector-Bagdady, Paul A Lombardo
Policy Points: While most scholarship regarding the US Public Health Service's STD experiments in Guatemala during the 1940s has focused on the intentional exposure experiments, secondary research was also conducted on biospecimens collected from these subjects. These biospecimen experiments continued after the Guatemala grant ended, and the specimens were used in conjunction with those from the Tuskegee syphilis experiments for ongoing research. We argue there should be a public accounting of whether there are still biospecimens from the Guatemala and Tuskegee experiments held in US government biorepositories today...
April 13, 2018: Milbank Quarterly
Elaine Xie, Meg Gemmill
OBJECTIVE: To identify psychosocial challenges facing pregnant women with intellectual and developmental disabilities (IDD) using retrospective, routinely collected electronic medical record data. DESIGN: A retrospective qualitative study using narratives and supporting documents found in the electronic medical record of an academic family health team (FHT). SETTING: Academic FHT in southeastern Ontario. PARTICIPANTS: A sample of 10 women with a diagnosis of IDD, rostered to physicians at the academic FHT, who delivered a child between January 2010 and June 2015 (14 pregnancies)...
April 2018: Canadian Family Physician Médecin de Famille Canadien
Ilias Chatzakis, Kostas Vassilakis, Christos Lionis, Ioannis Germanakis
BACKGROUND AND OBJECTIVE: Early detection of cardiovascular (CV) disease or associated risk factors during childhood is of paramount importance, allowing for early treatment or lifestyle modifications, respectively. The objective of this study was to describe the development of an electronic health record (EHR), with integrated computerized decision support system (CDSS), specifically designed for supporting the needs of a pilot pediatric CV disease screening program applied on primary school students of a Mediterranean island...
June 2018: Computer Methods and Programs in Biomedicine
Helene F Hedian, Jeremy A Greene, Timothy M Niessen
This review examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room...
May 2018: Medical Clinics of North America
Amanda Roxburgh, Jennifer L Pilgrim, Wayne D Hall, Lucinda Burns, Louisa Degenhardt
INTRODUCTION: Defining drug-related mortality is complex as these deaths can include a wide range of diseases and circumstances. This paper outlines a method to identify deaths that are directly due to fatal opioid toxicity (i.e. overdose), utilising coronial data. MATERIALS AND METHODS: The National Coronial Information System (NCIS), an online coronial database containing information on all deaths that are reported to a coroner in Australia, is used to develop methods to more accurately identify opioid overdose deaths...
March 26, 2018: Forensic Science International
Frank A Fanizza, Janelle F Ruisinger, Emily S Prohaska, Brittany L Melton
OBJECTIVE: To describe the incorporation of a state health information exchange (HIE) into a community pharmacy transitions of care (TOC) service and to assess its impact on 30-day readmission rates. SETTING: Three suburban community pharmacies in Olathe, Kansas. PRACTICE DESCRIPTION: Balls Food Stores is a grocery store chain which operates 21 supermarket community pharmacies in the Kansas City metropolitan area. PRACTICE INNOVATION: Balls Food Stores launched a pharmacist-led self-referral TOC study in which a state HIE was utilized to collect discharge information from patients' electronic medical records (EMRs) to facilitate TOC comprehensive medication reviews (CMRs)...
April 3, 2018: Journal of the American Pharmacists Association: JAPhA
Bryan A Wilbanks, Penni I Watts, Chad A Epps
During the last decade, the use of electronic health records (EHRs) in clinical settings has risen sharply. Many clinical education programs have not incorporated the use of electronic documentation into their curriculum. It is important to incorporate technologies that will be used in real-world settings into educational clinical simulations to better prepare students for clinical practice and promote patient safety. Electronic documentation can be harder to teach to students because it requires a more in-depth orientation on how to use the electronic documentation system and because health care organizations often give students limited or no access to the documentation system...
April 3, 2018: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
Emily D Carter, Micky Ndhlovu, Melinda Munos, Emmy Nkhama, Joanne Katz, Thomas P Eisele
Background: Accurate data on care-seeking for child illness are needed to improve public health programs and reduce child mortality. The accuracy of maternal report of care-seeking for child illness as collected through household surveys has not been validated. Methods: A 2016 survey compared reported care-seeking against a gold-standard of health care provider documented care-seeking events among a random sample of mothers of children <5 years in Southern Province, Zambia...
June 2018: Journal of Global Health
Leila Keikha, Seyede Sedigheh Seied Farajollah, Reza Safdari, Marjan Ghazisaeedi, Niloofar Mohammadzadeh
Background: In developing countries such as Iran, international standards offer good sources to survey and use for appropriate planning in the domain of electronic health records (EHRs). Therefore, in this study, HL7 and ASTM standards were considered as the main sources from which to extract EHR data. Objective: The objective of this study was to propose a hospital data set for a national EHR consisting of data classes and data elements by adjusting data sets extracted from the standards and paper-based records...
2018: Perspectives in Health Information Management
Hafdis Lilja Gudlaugsdottir, Arun Kristin Sigurdardottir
INTRODUCTION: Diabetes is a chronic disease often with serious and costly complications. Therefore well organised diabetes care is needed. The purpose was to research outcome of treatment on biological parameters in people with type one and two diabetes in one primary care over ten years and compare with international guidelines. MATERIAL AND METHODS: Retrospective cohort study, information was gathered from medical records at Sudurnes Health Center, in the years 2005, 2010 and 2015...
April 2018: Læknablađiđ
Linda Weiss, Maya Scherer, Tongtan Chantarat, Theo Oshiro, Patrick Padgen, Jose Pagan, Peri Rosenfeld, H Shonna Yin
Approximately 25 million people in the United States are limited English proficient (LEP). Appropriate language services can improve care for LEP individuals, and health care facilities receiving federal funds are required to provide such services. Recognizing the risk of inadequate comprehension of prescription medication instructions, between 2008 and 2012, New York City and State passed a series of regulations that require chain pharmacies to provide translated prescription labels and other language services to LEP patients...
April 3, 2018: Journal of Urban Health: Bulletin of the New York Academy of Medicine
Peter Magnusson, Hirsh Koyi, Gustav Mattsson
INTRODUCTION: Atrial fibrillation (AF) causes ischaemic stroke and based on risk factor evaluation warrants anticoagulation therapy. In stroke survivors, AF is typically detected with short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring requires substantial resources while insertable cardiac monitors are invasive and costly. Chest and thumb ECG could provide an alternative for AF detection poststroke.The primary objective of our study is to assess the incidence of newly diagnosed AF during 28 days of chest and thumb ECG monitoring in cryptogenic stroke...
April 3, 2018: BMJ Open
Harshad Hegde, Neel Shimpi, Ingrid Glurich, Amit Acharya
BACKGROUND: This cross-sectional retrospective study utilized Natural Language Processing (NLP) to extract tobacco-use associated variables from clinical notes documented in the Electronic Health Record (EHR). OBJECITVE: To develop a rule-based algorithm for determining the present status of the patient's tobacco-use. METHODS: Clinical notes (n= 5,371 documents) from 363 patients were mined and classified by NLP software into four classes namely: "Current Smoker", "Past Smoker", "Nonsmoker" and "Unknown"...
March 23, 2018: Technology and Health Care: Official Journal of the European Society for Engineering and Medicine
Ricardo Sánchez-de-Madariaga, Adolfo Muñoz, Antonio L Castro, Oscar Moreno, Mario Pascual
This research shows a protocol to assess the computational complexity of querying relational and non-relational (NoSQL (not only Structured Query Language)) standardized electronic health record (EHR) medical information database systems (DBMS). It uses a set of three doubling-sized databases, i.e. databases storing 5000, 10,000 and 20,000 realistic standardized EHR extracts, in three different database management systems (DBMS): relational MySQL object-relational mapping (ORM), document-based NoSQL MongoDB, and native extensible markup language (XML) NoSQL eXist...
March 19, 2018: Journal of Visualized Experiments: JoVE
Heather H Keller, Renata Valaitis, Celia V Laur, Tara McNicholl, Yingying Xu, Joel A Dubin, Lori Curtis, Suzanne Obiorah, Sumantra Ray, Paule Bernier, Leah Gramlich, Marilee Stickles-White, Manon Laporte, Jack Bell
BACKGROUND: Improving the detection and treatment of malnourished patients in hospital is needed to promote recovery. AIM: To describe the change in rates of detection and triaging of care for malnourished patients in 5 hospitals that were implementing an evidence-based nutrition care algorithm. To demonstrate that following this algorithm leads to increased detection of malnutrition and increased treatment to mitigate this condition. METHODS: Sites worked towards implementing the Integrated Nutrition Pathway for Acute Care (INPAC), including screening (Canadian Nutrition Screening Tool) and triage (Subjective Global Assessment; SGA) to detect and diagnose malnourished patients...
March 22, 2018: Clinical Nutrition: Official Journal of the European Society of Parenteral and Enteral Nutrition
Kevin T Bain, Emily J Schwartz, Orsula V Knowlton, Calvin H Knowlton, Jacques Turgeon
OBJECTIVES: To determine the feasibility of implementing a pharmacist-led pharmacogenomics (PGx) service for the Program of All-Inclusive Care for the Elderly (PACE). SETTING: A national centralized pharmacy providing PGx services to community-based PACE centers. PRACTICE DESCRIPTION: Individuals 55 years of age and older enrolled in PACE who underwent PGx testing as part of their medical care (n = 296). PRACTICE INNOVATION: Pharmacist-led PGx testing, interpreting, and consulting...
March 27, 2018: Journal of the American Pharmacists Association: JAPhA
Charles Senteio, Tiffany Veinot, Julia Adler-Milstein, Caroline Richardson
BACKGROUND: Psychosocial information informs clinical decisions by providing crucial context for patients' barriers to recommended self-care; this is especially important in outpatient diabetes care because outcomes are largely dependent upon self-care behavior. Little is known about provider perceptions of use of psychosocial information. Further, while EHRs have dramatically changed how providers interact with patient health information, the EHRs' role in collection and retrieval of psychosocial information is not understood...
May 2018: International Journal of Medical Informatics
Tobias Hodgson, Farah Magrabi, Enrico Coiera
OBJECTIVE: To conduct a usability study exploring the value of using speech recognition (SR) for clinical documentation tasks within an electronic health record (EHR) system. METHODS: Thirty-five emergency department clinicians completed a system usability scale (SUS) questionnaire. The study was undertaken after participants undertook randomly allocated clinical documentation tasks using keyboard and mouse (KBM) or SR. SUS scores were analyzed and the results with KBM were compared to SR results...
May 2018: International Journal of Medical Informatics
Anne C Spaulding, Ana Drobeniuc, Paula M Frew, Tiffany L Lemon, Emeli J Anderson, Colin Cerwonka, Chava Bowden, John Freshley, Carlos Del Rio
BACKGROUND: Linkage to and retention in care for US persons living with HIV (PLWH) after release from jail usually declines. We know of no rigorously evaluated behavioral interventions that can improve this. We hypothesized that a strengths-based case management intervention that we developed for PLWH leaving jail would increase linkage/retention in care (indicated by receipt of laboratory draws) and a suppressed HIV viral load (VL) in the year following release. METHODS AND FINDINGS: We conducted a quasi-experimental feasibility study of our intervention for PLWH jailed in Atlanta...
2018: PloS One
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