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Electronic discharge summary

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
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
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 We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or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
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...
February 21, 2018: Journal of Dairy Science
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
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
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
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
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
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
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
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...
October 24, 2017: Chemosphere
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
A Kortyna, A J Samin, T A Miller, D J Nesbitt
Highly reactive benzyl radicals are generated by electron dissociative attachment to benzyl chloride doped into a neon-hydrogen-helium discharge and immediately cooled to Trot = 15 K in a high density, supersonic slit expansion environment. The sub-Doppler spectra are fit to an asymmetric-top rotational Hamiltonian, thereby yielding spectroscopic constants for the ground (v = 0) and first excited (v = 1, ν3, ν4) vibrational levels of the ground electronic state. The rotational constants obtained for the ground state are in good agreement with previous laser induced fluorescence measurements (LIF), with vibrational band origins (ν3 = 3073...
November 3, 2017: Physical Chemistry Chemical Physics: PCCP
Siriwon Taewijit, Thanaruk Theeramunkong, Mitsuru Ikeda
Information extraction and knowledge discovery regarding adverse drug reaction (ADR) from large-scale clinical texts are very useful and needy processes. Two major difficulties of this task are the lack of domain experts for labeling examples and intractable processing of unstructured clinical texts. Even though most previous works have been conducted on these issues by applying semisupervised learning for the former and a word-based approach for the latter, they face with complexity in an acquisition of initial labeled data and ignorance of structured sequence of natural language...
2017: Journal of Healthcare Engineering
Muhammad Naeem Khan, Muhammad Qamar Masood, Mohammad Arsalan Siddiqui, Sabahat Naz, Najmul Islam
BACKGROUND: Hypercalcemia is a common clinical problem; primary hyperparathyroidism and malignancy is commonest causes of hypercalcemia. Aetiology of hypercalcemia are changing, causes that were diseases of the past like Vitamin-D toxicity and milk alkali syndrome are observed more often. Vitamin-D deficiency is an important problem and overzealous replacement of Vitamin-D has been observed, suspected to cause toxicity. METHODS: This was a retrospective review of patients admitted at the Aga Khan University Hospital from January 2008 to December 2013 with hypercalcemia...
July 2017: Journal of Ayub Medical College, Abbottabad: JAMC
Chien Hua Wu, Ruey Kei Chiu, Hong Mo Yeh, Da Wei Wang
In 2011, the Ministry of Health and Welfare of Taiwan established the National Electronic Medical Record Exchange Center (EEC) to permit the sharing of medical resources among hospitals. This system can presently exchange electronic medical records (EMRs) among hospitals, in the form of medical imaging reports, laboratory test reports, discharge summaries, outpatient records, and outpatient medication records. Hospitals can send or retrieve EMRs over the virtual private network by connecting to the EEC through a gateway...
November 2017: International Journal of Medical Informatics
S K Van Straten, C J Stannard, J Bulabula, K Paul, J Leong, M Klipin
BACKGROUND: South Africa has an overburdened public healthcare system. Some admissions to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) may not require tertiary care. The numbers and details thereof are uncertain. Clinical research is limited by skills and access to data. METHOD: A retrospective analysis of Electronic Discharge (ED) summaries from the Department of Surgery at CMJAH between 01 April 2015 and 01 April 2016. An SQL-query of the database generated a ...
June 2017: South African Journal of Surgery. Suid-Afrikaanse Tydskrif Vir Chirurgie
O Swart, J Pape, R Duvenage
BACKGROUND: There is limited published data describing the nature of surgical admissions at a regional level in the South African context. Worcester Hospital General Surgery has introduced an electronic online database to manage its surgical services. This study uses that database to evaluate the surgical burden of disease for the Cape Winelands East and Overberg districts of the Western Cape. METHOD: Admissions data were prospectively captured from February 2012 to January 2016, then retrospectively reviewed and classified into 5 types: (1) elective surgery/investigations (ESI); (2) trauma; (3) burns; (4) non-traumatic surgical emergencies (NTSE); (5) unplanned readmission within 30 days...
September 2017: South African Journal of Surgery. Suid-Afrikaanse Tydskrif Vir Chirurgie
S Van Straten, C Stannard, J Bulabula, K Boodhia, K Paul, J Leong, M J Klipin
BACKGROUND: South Africa (SA) has an overburdened public healthcare system. Some patients admitted to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), SA, may not require tertiary care, but the numbers and details are uncertain. Clinical research in SA is limited by scarce skills and limited access to data. OBJECTIVE: To determine the proportion of and length of stay for secondary-, tertiary- and quaternary-level patients discharged from the Department of Surgery at CMJAH over 1 year...
August 25, 2017: South African Medical Journal, Suid-Afrikaanse Tydskrif Vir Geneeskunde
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