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Electronic discharge summary

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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
#1
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
#2
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
#3
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
#4
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
#5
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
#6
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
#7
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
#8
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
#9
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
#10
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
https://www.readbyqxmd.com/read/28096249/natural-language-processing-to-extract-symptoms-of-severe-mental-illness-from-clinical-text-the-clinical-record-interactive-search-comprehensive-data-extraction-cris-code-project
#11
Richard G Jackson, Rashmi Patel, Nishamali Jayatilleke, Anna Kolliakou, Michael Ball, Genevieve Gorrell, Angus Roberts, Richard J Dobson, Robert Stewart
OBJECTIVES: We sought to use natural language processing to develop a suite of language models to capture key symptoms of severe mental illness (SMI) from clinical text, to facilitate the secondary use of mental healthcare data in research. DESIGN: Development and validation of information extraction applications for ascertaining symptoms of SMI in routine mental health records using the Clinical Record Interactive Search (CRIS) data resource; description of their distribution in a corpus of discharge summaries...
January 17, 2017: BMJ Open
https://www.readbyqxmd.com/read/28087072/enhancing-delirium-case-definitions-in-electronic-health-records-using-clinical-free-text
#12
Thomas H McCoy, Deanna C Chaukos, Leslie A Snapper, Kamber L Hart, Theodore A Stern, Roy H Perlis
BACKGROUND: Delirium is an acute confusional state, associated with morbidity and mortality in diverse medically ill populations. Delirium is preventable and treatable when diagnosed but the diagnosis is often missed. This important and difficult diagnosis is an attractive candidate for computer-aided decision support if it can be reliably identified at scale. OBJECTIVE: Here, using an electronic health record-based case definition of delirium, we characterize incidence of this highly morbid condition in 2 large academic medical centers...
March 2017: Psychosomatics
https://www.readbyqxmd.com/read/28067568/improving-community-prescribing-of-post-fracture-denosumab-after-discharge
#13
Helen Wood, Harriet Lewis, Rachael Ward, Tarun Solanki, Prabhath Fernando
BACKGROUND: In the UK, denosumab is usually started by hospital clinicians and continued by primary care physicians in the community, but in the authors' region denosumab is a 'green light' drug, only prescribed by the primary care team. The authors suspected that a proportion of patients who were recommended to start the drug after a neck of femur fracture were not receiving this on discharge. They aimed to improve the prescribing of denosumab by implementing a quality improvement project...
January 2, 2017: British Journal of Hospital Medicine
https://www.readbyqxmd.com/read/28045940/applying-the-integrated-practice-unit-concept-to-a-modified-virtual-ward-model-of-care-for-patients-at-highest-risk-of-readmission-a-randomized-controlled-trial
#14
Lian Leng Low, Shu Yun Tan, Matthew Joo Ming Ng, Wei Yi Tay, Lee Beng Ng, Kanchana Balasubramaniam, Rachel Marie Towle, Kheng Hock Lee
BACKGROUND: Emerging evidence from the virtual ward care model showed that multidisciplinary case management are inadequate to reduce readmissions or death for high risk patients. There is consensus that interventions should encompass both pre-hospital discharge and post-discharge transitional care to be effective. Integrated practice units (IPU) had been proposed as an approach of restructuring the organization and work processes of multidisciplinary teams to achieve value in healthcare...
2017: PloS One
https://www.readbyqxmd.com/read/27976370/droperidol-for-psychosis-induced-aggression-or-agitation
#15
REVIEW
Mariam A Khokhar, John Rathbone
BACKGROUND: People experiencing acute psychotic illnesses, especially those associated with agitated or violent behaviour, may require urgent pharmacological tranquillisation or sedation. Droperidol, a butyrophenone antipsychotic, has been used for this purpose in several countries. OBJECTIVES: To estimate the effects of droperidol, including its cost-effectiveness, when compared to placebo, other 'standard' or 'non-standard' treatments, or other forms of management of psychotic illness, in controlling acutely disturbed behaviour and reducing psychotic symptoms in people with schizophrenia-like illnesses...
December 15, 2016: Cochrane Database of Systematic Reviews
https://www.readbyqxmd.com/read/27920578/recording-of-hospitalizations-for-acute-exacerbations-of-copd-in-uk-electronic-health-care-records
#16
Kieran J Rothnie, Hana Müllerová, Sara L Thomas, Joht S Chandan, Liam Smeeth, John R Hurst, Kourtney Davis, Jennifer K Quint
BACKGROUND: Accurate identification of hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) within electronic health care records is important for research, public health, and to inform health care utilization and service provision. We aimed to develop a strategy to identify hospitalizations for AECOPD in secondary care data and to investigate the validity of strategies to identify hospitalizations for AECOPD in primary care data. METHODS: We identified patients with chronic obstructive pulmonary disease (COPD) in the Clinical Practice Research Datalink (CPRD) with linked Hospital Episodes Statistics (HES) data...
2016: Clinical Epidemiology
https://www.readbyqxmd.com/read/27821922/information-on-functioning-found-in-the-medical-records-of-patients-with-stroke
#17
Haejung Lee, Sunghwa Seo, Jumin Song
[Purpose] To explore data on functioning in the medical records of patients with stroke by linking them to the ICF. [Subjects and Methods] The admission and discharge summaries of patients' electronic medical records (EMRs) were investigated. Information on functioning included in the summaries were mapped into the ICF. Each of the linked categories of ICF was analyzed using frequency and percentage analysis. [Results] Thirty stroke patients' records were evaluated. A total of 1,832 items on functioning in the EMRs were found to be linked to eighty-five categories of the ICF...
October 2016: Journal of Physical Therapy Science
https://www.readbyqxmd.com/read/27797435/the-transition-of-care-between-emergency-department-and-primary-care-a-scoping-study
#18
Clare L Atzema, Laura C Maclagan
OBJECTIVES: Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge...
February 2017: Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
https://www.readbyqxmd.com/read/27754482/predicting-early-psychiatric-readmission-with-natural-language-processing-of-narrative-discharge-summaries
#19
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
https://www.readbyqxmd.com/read/27739662/structure-design-and-performance-tuning-of-nanomaterials-for-electrochemical-energy-conversion-and-storage
#20
Tian Sheng, Yue-Feng Xu, Yan-Xia Jiang, Ling Huang, Na Tian, Zhi-You Zhou, Ian Broadwell, Shi-Gang Sun
The performance of nanomaterials in electrochemical energy conversion (fuel cells) and storage (secondary batteries) strongly depends on the nature of their surfaces. Designing the structure of electrode materials is the key approach to achieving better performance. Metal or metal oxide nanocrystals (NCs) with high-energy surfaces and open surface structures have attained significant attention in the past decade since such features possess intrinsically exceptional properties. However, they are thermodynamically metastable, resulting in a huge challenge in their shape-controlled synthesis...
November 15, 2016: Accounts of Chemical Research
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