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Electronic discharge summary

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https://www.readbyqxmd.com/read/29726421/facilitating-the-information-exchange-using-a-modular-electronic-discharge-summary
#1
Kerstin Denecke, Pascal A Dittli, Niveadha Kanagarasa, Stephan Nüssli
BACKGROUND: Discharge summaries are a standard communication tool delivering important clinical information from inpatient to ambulatory care. To ensure a high quality, correctness and completeness, the generation process is time consuming. It requires also contributions of multiple persons. This is problematic since the primary care provider needs the information from the discharge summary for continuing the intended treatment. To address this challenge, we developed a concept for exchanging a modular electronic discharge summary...
2018: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/29716805/predictors-of-clinical-outcomes-among-patients-with-brain-abscess-in-thailand
#2
Thanyalak Amornpojnimman, Pat Korathanakhun
Although brain abscess is a fatal neurological infection, the studies in Thailand are quite limited and outdate. This study aims to identify predictors of mortality among patients with brain abscess in Thailand. Patients with a diagnosis of brain abscess admitted to Songklanagarind Hospital, a referral tertiary care hospital in southern Thailand, between 2002 and 2017 were enrolled into this retrospective case control study. Demographic data, neurological status, clinical presentations, predisposing factors, microbiological profiles, neuroimaging findings, treatments, and outcomes were collected from electronic medical records...
April 28, 2018: Journal of Clinical Neuroscience: Official Journal of the Neurosurgical Society of Australasia
https://www.readbyqxmd.com/read/29713202/derivation-and-validation-of-a-multivariable-model-to-predict-when-primary-care-physicians-prescribe-antidepressants-for-indications-other-than-depression
#3
Jenna Wong, Michal Abrahamowicz, David L Buckeridge, Robyn Tamblyn
Objective: Physicians commonly prescribe antidepressants for indications other than depression that are not evidence-based and need further evaluation. However, lack of routinely documented treatment indications for medications in administrative and medical databases creates a major barrier to evaluating antidepressant use for indications besides depression. Thus, the aim of this study was to derive a model to predict when primary care physicians prescribe antidepressants for indications other than depression and to identify important determinants of this prescribing practice...
2018: Clinical Epidemiology
https://www.readbyqxmd.com/read/29668920/impact-of-the-implementation-of-electronic-health-records-on-the-quality-of-discharge-summaries-and-on-the-coding-of-hospitalization-episodes
#4
José L Bernal, Sebastián DelBusto, María I García-Mañoso, Emilia de Castro Monteiro, Ángel Moreno, Carolina Varela-Rodríguez, Pedro M Ruiz-Lopez
Objective: To determine whether the implementation and use of the electronic health records (EHR) modifies the quality, readability and/or the length of the discharge summaries (DS) and the average number of coded diagnosis and procedures per hospitalization episode. Design: A pre-post-intervention descriptive study conducted between 2010 and 2014. Setting: The 'Hospital Universitario 12 de Octubre' (H12O) of Madrid (Spain). A tertiary University Hospital of up to 1200 beds...
April 13, 2018: International Journal for Quality in Health Care
https://www.readbyqxmd.com/read/29610769/improving-driving-advice-provided-to-cardiology-patients-on-discharge
#5
Amoolya Vusirikala, Mark Backhouse, Sarah Schimansky
Certain cardiac conditions can limit patients' ability to drive. It remains the doctors' responsibility to advise patients of any driving restrictions and is particularly important after certain diagnoses or procedures. We identified that the quality of documented advice was variable and frequently no written driving advice was recorded on discharge. It was apparent that there was a lack of awareness and knowledge of the current Driving and Vehicle Licensing Agency (DVLA) guidance among junior doctors. We therefore designed a quality improvement project using Plan-Do-Study-Act (PDSA) methodology to improve the provision of driving advice on discharge from a cardiology ward by focusing on staff education...
2018: BMJ Open Quality
https://www.readbyqxmd.com/read/29587532/an-audit-of-the-accuracy-of-medication-information-in-electronic-medical-discharge-summaries-linked-to-an-electronic-prescribing-system
#6
Yixin Tan, Rohan A Elliott, Belinda Richardson, Francine E Tanner, Michael I Dorevitch
BACKGROUND: Poor communication of medication information to general practitioners when patients are discharged from hospital is a widely recognised problem. There has been little research exploring the accuracy of medication information in electronic discharge summaries (EDS) linked to hospital e-prescribing systems. OBJECTIVE: To evaluate the accuracy of medication lists and medication change information in EDS produced using an integrated e-prescribing and EDS system (where EDS discharge medication lists were imported from discharge e-prescription records, medication change information was manually entered, and medications were dispensed from paper copies of the patients' e-prescriptions)...
January 1, 2018: Health Information Management: Journal of the Health Information Management Association of Australia
https://www.readbyqxmd.com/read/29578553/trends-in-inpatient-admission-comorbidity-and-electronic-health-data-implications-for-resident-workload-intensity
#7
Amanda V Clark, Charles M LoPresti, Todd I Smith
In the era of duty hour regulations, there is increasing concern regarding resident workload compression. We conducted a retrospective, observational assessment of all internal medicine resident admissions to a Veterans Affairs hospital over a 15-year period to evaluate several admission components that impact resident workload and workload intensity, including electronic health record (EHR) data burden and patient comorbidity. A total of 67,346 admissions were included in the analysis. Mean patient comorbidity, as measured by the Charlson Comorbidity Index, increased throughout the study period...
March 26, 2018: Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine
https://www.readbyqxmd.com/read/29503423/-current-status-and-issues-of-electronic-information-provision-for-risk-minimization-coordination-between-electronic-medicine-notebook-and-patient-drug-information
#8
REVIEW
Takao Orii
 In the collaboration between community pharmacies and hospitals or clinics, the use of electronic medicine notebook may allow information sharing, including among out-of-network hospitals, clinics, and community pharmacies. For risk minimization, mobile or smart phones, which patients always carry with them, should be used as a tool allowing drug information to be accessed at any time. An advantage of the electronic conversion of patient drug information is that it allows patients not only to obtain round-the-clock information on drugs, etc...
2018: Yakugaku Zasshi: Journal of the Pharmaceutical Society of Japan
https://www.readbyqxmd.com/read/29494750/pulse-oximetry-screening-for-critical-congenital-heart-defects
#9
REVIEW
Maria N Plana, Javier Zamora, Gautham Suresh, Luis Fernandez-Pineda, Shakila Thangaratinam, Andrew K Ewer
BACKGROUND: Health outcomes are improved when newborn babies with critical congenital heart defects (CCHDs) are detected before acute cardiovascular collapse. The main screening tests used to identify these babies include prenatal ultrasonography and postnatal clinical examination; however, even though both of these methods are available, a significant proportion of babies are still missed. Routine pulse oximetry has been reported as an additional screening test that can potentially improve detection of CCHD...
March 1, 2018: Cochrane Database of Systematic Reviews
https://www.readbyqxmd.com/read/29489926/interventions-to-improve-follow-up-of-laboratory-test-results-pending-at-discharge-a-systematic-review
#10
Nedra S Whitehead, Laurina Williams, Sreelatha Meleth, Sara Kennedy, Paul Epner, Hardeep Singh, Kathleene Wooldridge, Anuj K Dalal, Stacy E Walz, Tom Lorey, Mark L Graber
Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD...
February 28, 2018: Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine
https://www.readbyqxmd.com/read/29477521/changes-in-feeding-social-and-lying-behaviors-in-dairy-cows-with-metritis-following-treatment-with-a-nonsteroidal-anti-inflammatory-drug-as-adjunctive-treatment-to-an-antimicrobial
#11
J Lomb, H W Neave, D M Weary, S J LeBlanc, J M Huzzey, M A G von Keyserlingk
Dairy cows with metritis display sickness behaviors, and nonsteroidal anti-inflammatory drugs (NSAID) have the potential to reduce these responses. The objective of this study was to investigate changes in feeding, social, and lying behaviors in dairy cows with metritis that had been treated with the NSAID meloxicam. After parturition, cows were housed in a dynamic, mixed-parity group of 20 animals with access to 12 electronic feed bins, 2 electronic water bins, and 24 lying stalls in a freestall pen. Every third day after parturition, vaginal discharge was evaluated to diagnose metritis based on the presence of foul smell and characteristic visual appearance...
May 2018: Journal of Dairy Science
https://www.readbyqxmd.com/read/29447188/comparing-deep-learning-and-concept-extraction-based-methods-for-patient-phenotyping-from-clinical-narratives
#12
COMPARATIVE STUDY
Sebastian Gehrmann, Franck Dernoncourt, Yeran Li, Eric T Carlson, Joy T Wu, Jonathan Welt, John Foote, Edward T Moseley, David W Grant, Patrick D Tyler, Leo A Celi
In secondary analysis of electronic health records, a crucial task consists in correctly identifying the patient cohort under investigation. In many cases, the most valuable and relevant information for an accurate classification of medical conditions exist only in clinical narratives. Therefore, it is necessary to use natural language processing (NLP) techniques to extract and evaluate these narratives. The most commonly used approach to this problem relies on extracting a number of clinician-defined medical concepts from text and using machine learning techniques to identify whether a particular patient has a certain condition...
2018: PloS One
https://www.readbyqxmd.com/read/29426318/hospital-discharge-documentation-of-a-designated-clinician-for-follow-up-care-and-30-day-outcomes-in-hip-fracture-and-stroke-patients-discharged-to-sub-acute-care
#13
Andrea L Gilmore-Bykovskyi, Korey A Kennelty, Eva DuGoff, Amy J H Kind
BACKGROUND: Transitions to sub-acute care are regularly complicated by inadequate discharge communication, which is exacerbated by a lack of clarity regarding accountability for important follow-up care. Patients discharged to sub-acute care often have complex medical conditions and are at heightened risk for poor post-hospital outcomes, yet many do not see a provider until 30 days post discharge due to current standards in Medicare regulations. Lack of designation of a responsible clinician or clinic for follow-up care may adversely impact patient outcomes, but the magnitude of this potential impact has not been previously studied...
February 9, 2018: BMC Health Services Research
https://www.readbyqxmd.com/read/29352419/a-systematic-review-of-interventions-to-follow-up-test-results-pending-at-discharge
#14
Patrick J Darragh, T Bodley, A Orchanian-Cheff, K G Shojania, J L Kwan, P Cram
BACKGROUND: Patients are frequently discharged from the hospital before all test results have been finalized. Thirty to 40% of tests pending at discharge (TPADs) return potentially actionable results that could necessitate change in the patients' management, often unbeknownst to their physicians. Delayed follow-up of TPADs can lead to patient harm. We sought to synthesize the existing literature on interventions intended to improve the management of TPADs, including interventions designed to enhance documentation of TPADs, increase physician awareness when TPAD results finalize post-discharge, decrease adverse events related to missed TPADs, and increase physician satisfaction with TPAD management...
January 19, 2018: Journal of General Internal Medicine
https://www.readbyqxmd.com/read/29247110/prospective-economic-evaluation-of-an-electronic-discharge-communication-tool-analysis-of-a-randomised-controlled-trial
#15
Laura K Sevick, Maria-Jose Santana, William A Ghali, Fiona Clement
OBJECTIVE: To complete an economic evaluation within a randomised controlled trial (RCT) comparing the use of an electronic discharge communication tool (eDCT) compared with usual care. SETTING: Patients being discharged from a single tertiary care centre's internal medicine Medical Teaching Units. PARTICIPANTS: Between January 2012 and December 2013, 1399 patients were randomised to a discharge mechanism. Forty-five patients were excluded from the economic evaluation as they did not have data for the index hospitalisation cost; 1354 patients contributed to the economic evaluation...
December 14, 2017: BMJ Open
https://www.readbyqxmd.com/read/29229645/the-incidence-of-military-training-related-injuries-in-chinese-new-recruits-a-systematic-review-and-meta-analysis
#16
REVIEW
Wei Hua, Q Chen, M Wan, J Lu, L Xiong
INTRODUCTION: Training-related injuries are the main reason for disability, long-term rehabilitation, functional impairment and premature discharge from military service. The aim of this study was to identify the incidence of injuries in the training of Chinese new recruits via a systematic review of the literature. METHOD: A systematic review and meta-analysis was conducted to evaluate the combined incidence of military training-related injuries in Chinese new recruits...
December 10, 2017: Journal of the Royal Army Medical Corps
https://www.readbyqxmd.com/read/29180550/information-transfer-and-the-hospital-discharge-summary-national-primary-care-provider-perspectives-of-challenges-and-opportunities
#17
Paul M Robelia, Deanne T Kashiwagi, Sarah M Jenkins, James S Newman, Atsushi Sorita
PURPOSE: The hospital discharge summary (HDS) serves as a critical method of patient information transfer between hospitalist and primary care provider (PCP). This study was designed to increase our understanding of PCP preferences for, and perceived deficiencies in, the discharge summary. METHODS: We designed a mail survey that was sent to a random sample of 800 American Academy of Family Physicians members nationally. The survey response rate was 59%. We analyzed the availability of summaries at hospital followup, whether all desired information was contained in the summary and whether certain specific items were completed...
November 2017: Journal of the American Board of Family Medicine: JABFM
https://www.readbyqxmd.com/read/29180543/multiple-practical-facts-and-ideas-to-improve-family-medicine-care
#18
EDITORIAL
Marjorie A Bowman, Dean A Seehusen, Anne Victoria Neale
Seconds count in a study on the best electronic health note format to reduce medical record charting time and increase accuracy. Directly observed family physician work is compared with Current Procedural Terminology (CPT) coding examples and notably under-recognized. This issue contains articles from single practices that that implemented new methods of care and other reports on practice innovations that can be more broadly implemented. We have articles on opioid medication use for acute low back pain in primary care, an electronic chronic pain consult service, a key question to identify potential opioid misuse risk, and newly implemented screening for other substances of abuse...
November 2017: Journal of the American Board of Family Medicine: JABFM
https://www.readbyqxmd.com/read/29107880/fine-particulate-air-pollution-and-hospital-admissions-and-readmissions-for-acute-myocardial-infarction-in-26-chinese-cities
#19
Hui Liu, Yaohua Tian, Yaying Cao, Jing Song, Chao Huang, Xiao Xiang, Man Li, Yonghua Hu
Monitoring data on fine particulate matter (PM2.5 ) level in China's major cities were available since 2013. We conducted a time-stratified case-crossover study to evaluate the association between short-term exposure to PM2.5 and hospital admissions for acute myocardial infarction (AMI), as well as subsequent cardiac and AMI readmissions among AMI survivors. Hospital admissions for ST-elevation myocardial infarction (STEMI) and non ST-elevation myocardial infarction (NSTEMI) from 1 January 2014 through 31 December 2015 were identified from electronic Hospitalization Summary Reports...
February 2018: Chemosphere
https://www.readbyqxmd.com/read/29101617/quality-of-medication-information-in-discharge-summaries-from-hospitals-an-audit-of-electronic-patient-records
#20
Beate Hennie Garcia, Berit Svendsen Djønne, Frode Skjold, Ellen Marie Mellingen, Trine Iversen Aag
Background Low quality of medication information in discharge summaries from hospitals may jeopardize optimal therapy and put the patient at risk for medication errors and adverse drug events. Objective To audit the quality of medication information in discharge summaries and explore factors associated with the quality. Setting Helgelandssykehuset Mo i Rana, a rural hospital in central Norway. Method For each month in 2013, we randomly selected 60 discharge summaries from the Department of Medicine and Surgery (totally 720) and evaluated the medication information using eight Norwegian quality criteria...
December 2017: International Journal of Clinical Pharmacy
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