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Electronic discharge summary

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https://www.readbyqxmd.com/read/28789686/developing-a-cardiovascular-disease-risk-factor-annotated-corpus-of-chinese-electronic-medical-records
#1
Jia Su, Bin He, Yi Guan, Jingchi Jiang, Jinfeng Yang
BACKGROUND: Cardiovascular disease (CVD) has become the leading cause of death in China, and most of the cases can be prevented by controlling risk factors. The goal of this study was to build a corpus of CVD risk factor annotations based on Chinese electronic medical records (CEMRs). This corpus is intended to be used to develop a risk factor information extraction system that, in turn, can be applied as a foundation for the further study of the progress of risk factors and CVD. RESULTS: We designed a light annotation task to capture CVD risk factors with indicators, temporal attributes and assertions that were explicitly or implicitly displayed in the records...
August 8, 2017: BMC Medical Informatics and Decision Making
https://www.readbyqxmd.com/read/28739535/importance-and-feasibility-of-transitional-care-for-children-with-medical-complexity-results-of-a-multi-stakeholder-delphi-process
#2
JoAnna K Leyenaar, Paul A Rizzo, Dmitry Khodyakov, Laurel K Leslie, Peter K Lindenauer, Rita Mangione-Smith
BACKGROUND: Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes following discharge, and several gaps exist regarding the quality of hospital-to-home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital-to-home transitional care interventions for CMC from the perspectives of parents and healthcare professionals. METHODS: We conducted a two-round electronic Delphi process to identify important and feasible transitional care interventions...
July 21, 2017: Academic Pediatrics
https://www.readbyqxmd.com/read/28662984/mr-enterography-in-crohn-s-disease-complicated-with-enteroenteric-fistula
#3
Ayşe Erden, Sena Ünal, Habip Eser Akkaya, Mehmet Onay, Murat Törüner, Zeynep Bıyıklı Gençtürk, Aysun Çalışkan Kartal
OBJECTIVE: In this retrospective study, we aimed to evaluate MR enterography (MRE) findings, MR index of activity (MaRIA) and laboratory markers in Crohn patients with enteroenteric fistula. METHODS: Institution's electronic medical records (laboratory, pathology, ileocolonoscopy results and discharge summary) were reviewed and MR images retrieved from the PACS were reanalyzed in Crohn patients assessed at Gastroenterology Clinic of our university between July 2011 and July 2016...
June 20, 2017: European Journal of Radiology
https://www.readbyqxmd.com/read/28653940/review-medication-errors-and-strategies-for-their-prevention
#4
Muhammad Kashif Riaz, Mohammad Riaz, Abida Latif
Medication errors occur every day causing injury to the patients and even deaths. The health care professionals are not fully aware of the damages done by medication errors in terms of patients' discomfort and economic burden. There is a need to provide information about medication errors to health care providers. This article reviews research done on the various aspects of medication errors. The research work done on prescribing errors, transcribing errors, dispensing errors, administration errors and discharged summaries errors have been examined...
May 2017: Pakistan Journal of Pharmaceutical Sciences
https://www.readbyqxmd.com/read/28638780/materials-design-and-system-construction-for-conventional-and-new-concept-supercapacitors
#5
REVIEW
Zhong Wu, Lin Li, Jun-Min Yan, Xin-Bo Zhang
With the development of renewable energy and electrified transportation, electrochemical energy storage will be more urgent in the future. Supercapacitors have received extensive attention due to their high power density, fast charge and discharge rates, and long-term cycling stability. During past five years, supercapacitors have been boomed benefited from the development of nanostructured materials synthesis and the promoted innovation of devices construction. In this review, we have summarized the current state-of-the-art development on the fabrication of high-performance supercapacitors...
June 2017: Advanced Science (Weinheim, Baden-Wurttemberg, Germany)
https://www.readbyqxmd.com/read/28622808/characterizing-and-predicting-rates-of-delirium-across-general-hospital-settings
#6
Thomas H McCoy, Kamber L Hart, Roy H Perlis
OBJECTIVE: To better understand variation in reported rates of delirium, this study characterized delirium occurrence rate by department of service and primary admitting diagnosis. METHOD: Nine consecutive years (2005-2013) of general hospital admissions (N=831,348) were identified across two academic medical centers using electronic health records. The primary admitting diagnosis and the treating clinical department were used to calculate occurrence rates of a previously published delirium definition composed of billing codes and natural language processing of discharge summaries...
May 2017: General Hospital Psychiatry
https://www.readbyqxmd.com/read/28572220/msoar-an-effective-bedside-stroke-prognosis-tool
#7
Mark Thaller, Nicholas Mitchell
The modified-SOAR (mSOAR) score is composed of the stroke subtype, Oxfordshire Community Stroke Project classification, age, pre-stroke modified Rankin score (mRS) and the National Institutes of Health Stroke Scale score. It has previously been shown to be a reliable predictor of mortality and length of -hospital stay. This study sought to identify whether the mSOAR can also be used to predict patient disability on discharge. A post-hoc calculation of mSOAR using Sentinel Stroke National Audit Programme (SSNAP) data and electronic discharge -summaries was performed on all stroke admissions to Bridgend Hospital over an 11-month period...
June 2017: Clinical Medicine: Journal of the Royal College of Physicians of London
https://www.readbyqxmd.com/read/28559030/the-effect-of-utilization-review-on-emergency-department-operations
#8
Shoma Desai, Phillip F Gruber, Erick Eiting, Seth A Seabury, Wendy J Mack, Christian Voyageur, Veronica Vasquez, Hyung T Kim, Sophie Terp
STUDY OBJECTIVE: Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. METHODS: In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria...
May 27, 2017: Annals of Emergency Medicine
https://www.readbyqxmd.com/read/28509435/inpatient-iron-deficiency-detection-and-management-how-do-general-physicians-and-gastroenterologists-perform-in-a-tertiary-care-hospital
#9
Muhammad W Fazal, Jane M Andrews, Josephine Thomas, Eliana Saffouri
BACKGROUND: Iron deficiency (ID) is often an indicator of underlying pathology. Early detection and treatment avoids long-term morbidity and allows for prompt iron repletion, avoiding ID anaemia (IDA) and the need for blood transfusion. AIM: To evaluate the management of ID in two internal medicine units (general medical (GM) and gastroenterology (GE)) in a large metropolitan hospital and compare it to international guidelines. METHODS: All consecutive inpatient admissions in the GM and GE units were retrospectively reviewed until 40 patients in each service were identified with anaemia and/or microcytic hypochromic blood counts...
August 2017: Internal Medicine Journal
https://www.readbyqxmd.com/read/28491308/novel-combined-patient-instruction-and-discharge-summary-tool-improves-timeliness-of-documentation-and-outpatient-provider-satisfaction
#10
Meredith Gilliam, Sarah L Krein, Karen Belanger, Karen E Fowler, Derek E Dimcheff, Gabriel Solomon
BACKGROUND: Incomplete or delayed access to discharge information by outpatient providers and patients contributes to discontinuity of care and poor outcomes. OBJECTIVE: To evaluate the effect of a new electronic discharge summary tool on the timeliness of documentation and communication with outpatient providers. METHODS: In June 2012, we implemented an electronic discharge summary tool at our 145-bed university-affiliated Veterans Affairs hospital...
2017: SAGE Open Medicine
https://www.readbyqxmd.com/read/28398701/cervical-pessary-for-preventing-preterm-birth-in-singleton-pregnancies-with-short-cervical-length-a-systematic-review-and-meta-analysis
#11
Gabriele Saccone, Andrea Ciardulli, Serena Xodo, Lorraine Dugoff, Jack Ludmir, Giorgio Pagani, Silvia Visentin, Salvatore Gizzo, Nicola Volpe, Giuseppe Maria Maruotti, Giuseppe Rizzo, Pasquale Martinelli, Vincenzo Berghella
OBJECTIVES: To evaluate the effectiveness of cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with a second trimester short cervix. METHODS: Electronic databases were searched from their inception until February 2016. We included randomized clinical trials (RCTs) comparing the use of the cervical pessary with expectant management in singletons pregnancies with transvaginal ultrasound cervical length (TVU CL) ≤25 mm. The primary outcome was incidence of SPTB <34 weeks...
April 11, 2017: Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine
https://www.readbyqxmd.com/read/28334559/design-and-hospitalwide-implementation-of-a-standardized-discharge-summary-in-an-electronic-health-record
#12
Shannon M Dean, Andrea Gilmore-Bykovskyi, Joel Buchanan, Brad Ehlenfeldt, Amy J H Kind
BACKGROUND: The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to posthospital care, incomplete discharge summaries remain a common problem that may contribute to poor posthospital outcomes. Electronic health records (EHRs) are regularly used as a platform on which standardization of content and format can be implemented...
December 2016: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28272593/the-unmet-need-for-postacute-rehabilitation-among-medicare-observation-patients-a-single-center-study
#13
Jennifer N Goldstein, J Sanford Schwartz, Patricia McGraw, Tobias L Banks, LeRoi S Hicks
BACKGROUND: Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs. OBJECTIVE: To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization. DESIGN/SETTING: Observational study using electronic medical record and administrative data from a regional health system...
March 2017: Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine
https://www.readbyqxmd.com/read/28260602/recovery-after-abdominal-wall-reconstruction
#14
REVIEW
Kristian Kiim Jensen
Incisional hernia is a common long-term complication to abdominal surgery, occurring in more than 20% of all patients. Some of these hernias become giant and affect patients in several ways. This patient group often experiences pain, decreased perceived body image, and loss of physical function, which results in a need for surgical repair of the giant hernia, known as abdominal wall reconstruction. In the current thesis, patients with a giant hernia were examined to achieve a better understanding of their physical and psychological function before and after abdominal wall reconstruction...
March 2017: Danish Medical Journal
https://www.readbyqxmd.com/read/28244546/structuring-legacy-pathology-reports-by-openehr-archetypes-to-enable-semantic-querying
#15
Stefan Kropf, Peter Krücken, Wolf Mueller, Kerstin Denecke
BACKGROUND: Clinical information is often stored as free text, e.g. in discharge summaries or pathology reports. These documents are semi-structured using section headers, numbered lists, items and classification strings. However, it is still challenging to retrieve relevant documents since keyword searches applied on complete unstructured documents result in many false positive retrieval results. OBJECTIVES: We are concentrating on the processing of pathology reports as an example for unstructured clinical documents...
February 28, 2017: Methods of Information in Medicine
https://www.readbyqxmd.com/read/28178023/risk-factors-for-acute-care-hospital-readmission-in-older-persons-in-western-countries-a-systematic-review
#16
Mona Kyndi Pedersen, Gabriele Meyer, Lisbeth Uhrenfeldt
BACKGROUND: Hospital readmission in older persons is common and reported as a post-discharge adverse outcome from hospitalization. Readmission relates to a mix of factors associated with increasing age, living conditions, progression of disease as well as factors related to the processes of care. To allow health professionals to focus more intensively on patients at risk of readmission, there is a need to identify the characteristics of those patients. OBJECTIVES: To identify and synthesize the best available evidence on risk factors for acute care hospital readmission within one month of discharge in older persons in Western countries...
February 2017: JBI Database of Systematic Reviews and Implementation Reports
https://www.readbyqxmd.com/read/28152940/code-status-documentation-in-the-electronic-medical-record-for-patients-with-stage-iv-pancreatic-cancer
#17
Janet M Armstrong, Joseph D Ma, Carolyn Revta, Eric Roeland
125 Background: Improving incidence of code status documentation in the electronic medical record (EMR) has been suggested a better guidance for clinical care compared with a traditional advance directive. We have previously reported that in the absence of a template in the EMR, code status documentation was 36% and inconsistent in patients with advanced cancer. Utilizing a different cohort of patients with metastatic pancreatic cancer, we examined the prevalence of EMR code status documentation. METHODS: A retrospective analysis in patients with analytic metastatic pancreatic cancer (2008-2014) was conducted at a single, academic medical center...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28152819/electronic-operative-reports-to-support-quality-improvement-and-patient-centered-care
#18
Elaine Maloney, Mary Agent-Katwala, Geoff Porter
95 Background: Operative reports (OP) for cancer surgery are usually narrated, although they provide inconsistent and incomplete information for patient care. National standards for cancer OP were unavailable until 2007. Over 10 years, surgeons in four Canadian provinces have transitioned from narrative to electronic synoptic reporting (ESP) for specific cancers. The electronic OP are now considered a patient medical record and integral to subsequent patient care. Surgeons are using electronic reports for quality assurance, billing, medical-legal conflict resolution and research...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28123748/the-e-crabel-score-an-updated-method-for-auditing-medical-records
#19
Tharsika Myuran, Oliver Turner, Bijan Ben Doostdar, Bryony Lovett
In 2001 the CRABEL score was devised in order to obtain a numerical score of the standard of medical note keeping. With the advent of electronic discharge letters, many components of the CRABEL score are now redundant as computers automatically include some documentation. The CRABEL score was modified to form the e-CRABEL score. "Patient details on discharge letter" and "Admission and discharge dates on discharge letter" were replaced with "Summary of investigations on discharge letter" and "Documentation of VTE prophylaxis on the drug chart"...
2017: BMJ Quality Improvement Reports
https://www.readbyqxmd.com/read/28104042/electronic-health-records-and-online-medical-records-an-asset-or-a-liability-under-current-conditions
#20
Judith Allen-Graham, Lauren Mitchell, Natalie Heriot, Roksana Armani, David Langton, Michele Levinson, Alan Young, Julian A Smith, Tom Kotsimbos, John W Wilson
Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information.Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital's current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary...
January 20, 2017: Australian Health Review: a Publication of the Australian Hospital Association
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