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Electronic discharge summary

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
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...
October 14, 2016: Accounts of Chemical Research
Shahram Tahmasebian, Mostafa Langarizadeh, Marjan Ghazisaeidi, Mitra Mahdavi-Mazdeh
INTRODUCTION: Case-based reasoning (CBR) systems are one of the effective methods to find the nearest solution to the current problems. These systems are used in various spheres as well as industry, business, and economy. The medical field is not an exception in this regard, and these systems are nowadays used in the various aspects of diagnosis and treatment. METHODOLOGY: In this study, the effective parameters were first extracted from the structured discharge summary prepared for patients with chronic kidney diseases based on data mining method...
July 16, 2016: Acta Informatica Medica: AIM
Sze Ling Chan, Mun Yee Tham, Siew Har Tan, Celine Loke, Belinda Foo, Yanping Fan, Pei San Ang, Liam R Brunham, Cynthia Sung
The aim of this study was to develop and validate sensitive algorithms to detect hospitalized statin-induced myopathy (SIM) cases from electronic medical records (EMRs). We developed 4 algorithms on a training set of 31,211 patient records from a large tertiary hospital. We determined the performance of these algorithms against manually curated records. The best algorithm used a combination of elevated creatine kinase (>4x upper limit of normal), discharge summary, diagnosis, and absence of statin in discharge medications...
October 5, 2016: Clinical Pharmacology and Therapeutics
Maxim Topaz, Kenneth Lai, Dawn Dowding, Victor J Lei, Anna Zisberg, Kathryn H Bowles, Li Zhou
BACKGROUND: Electronic health records are being increasingly used by nurses with up to 80% of the health data recorded as free text. However, only a few studies have developed nursing-relevant tools that help busy clinicians to identify information they need at the point of care. OBJECTIVE: This study developed and validated one of the first automated natural language processing applications to extract wound information (wound type, pressure ulcer stage, wound size, anatomic location, and wound treatment) from free text clinical notes...
September 19, 2016: International Journal of Nursing Studies
Mithilesh Dronavalli, Manavi M Bhagwat, Sandy Hamilton, Marisa Gilles, Jacquie Garton-Smith, Sandra C Thompson
Patients with acute coronary syndrome (ACS) require ongoing treatment and support from their primary care provider to modify cardiovascular risk factors (including diet, exercise and mood), to receive evidence-based pharmacotherapies and be properly monitored and to ensure their take-up and completion of cardiac rehabilitation (CR). This study assesses adherence to National Heart Foundation guidelines for ACS in primary care in a regional centre in Western Australia. Patients discharged from hospital after a coronary event (unstable angina or myocardial infarction) or a coronary procedure (stent or coronary artery bypass graft) were identified through general practice electronic medical records...
September 20, 2016: Australian Journal of Primary Health
Maxim Topaz, Kavita Radhakrishnan, Suzanne Blackley, Victor Lei, Kenneth Lai, Li Zhou
This study developed an innovative natural language processing algorithm to automatically identify heart failure (HF) patients with ineffective self-management status (in the domains of diet, physical activity, medication adherence, and adherence to clinician appointments) from narrative discharge summary notes. We also analyzed the association between self-management status and preventable 30-day hospital readmissions. Our natural language system achieved relatively high accuracy (F-measure = 86.3%; precision = 95%; recall = 79...
September 14, 2016: Western Journal of Nursing Research
Ros Wade, Fiona Paton, Nerys Woolacott
AIM: The aim of this study was to explore patient preference and adherence to thigh and knee length graduated compression stockings for the prevention of deep vein thrombosis in surgical patients. BACKGROUND: Hospitalised patients are at risk of developing deep vein thrombosis. Mechanical methods of prophylaxis include compression stockings, available as knee or thigh length. Patient adherence to correct stocking use is of critical importance to their effectiveness...
September 14, 2016: Journal of Advanced Nursing
Joshua W Joseph, David T Chiu, Larry A Nathanson, Steven Horng
OBJECTIVES: To evaluate the sensitivity and specificity of a problem list automatically generated from the emergency department (ED) medication reconciliation. METHODS: We performed a retrospective cohort study of patients admitted via the ED who also had a prior inpatient admission within the past year of an academic tertiary hospital. Our algorithm used the First Databank ontology to group medications into therapeutic classes, and applied a set of clinically derived rules to them to predict obstructive lung disease, hypertension, diabetes, congestive heart failure (CHF), and thromboembolism (TE) risk...
October 2016: International Journal of Medical Informatics
Amanda Bevan, Niesh Patel
BACKGROUND: Whilst the prescribing of both in-patient and discharge medicines is electronic, there was no automatic notification to clinical pharmacists when a discharge prescription was ready to be screened. The notification required a member of medical or nursing staff to bleep their pharmacist informing them of a prescription's availability. This manual process led to a delay in pharmacist screening which impacted on discharge. Prescriptions designated for pre-packed or patient's own medicine use were not seen at all by a clinical pharmacist...
September 2016: Archives of Disease in Childhood
Maria Moss, Celine Bilbul, Jo Crook
INTRODUCTION: National guidance from National Institute for Health and Clinical Excellence (NICE), National Patient Safety Agency (NPSA), World Health Organization and the Royal Pharmaceutical Society has long highlighted the importance of accurate and timely medicines reconciliation (MR) in reducing medication errors for patients upon transfer of care setting.1 (-) 4 Current guidance for MR excludes children <16 years of age, where widespread use of off-label and unlicensed formulations puts this group of patients at a higher risk...
September 2016: Archives of Disease in Childhood
Reema Harrison, Merrilyn Walton, Elizabeth Manias, Steven Mears, Jennifer Plumb
Objective Patients are uniquely positioned to provide insightful comments about their care. Currently, a lack of comparable patient experience data prevents the emergence of a detailed picture of patients' experiences in Australian hospitals. The present study addresses this gap by identifying factors reported in primary research as relating to positive and negative experiences of patients in Australian hospitals.Methods Evidence from Australian qualitative studies of patients of all ages reporting their experiences in any hospital or day procedure centre was synthesised...
August 19, 2016: Australian Health Review: a Publication of the Australian Hospital Association
Selwa Elrouby, Mary P Tully
BACKGROUND: There is evidence that the transfer of information on medication changes on patient discharge summaries is poor. By considering the completion of an electronic discharge summary as a behavior, the various components of the behavior can be targeted to improve their completion so that they consistently include information on medication changes. OBJECTIVES: Study objectives were to identify the barriers and facilitators to junior doctors completing information on medication changes on electronic discharge summaries, including why these occurred...
June 23, 2016: Research in Social & Administrative Pharmacy: RSAP
Afaf H A Elayyat, Ahmed Sadek
BACKGROUND: The Theodor Bilharz Research Institute (TBRI) Hospital is a research and referral center for gastroenterology and hepatology. The Hepatogastroenterology (HGE) Department in TBRI Hospital is a center for endoscopy and sonography. The department also has a hepatology ICU. As a part of hospital performance improvement, medical records that satisfy the needs and demands of the healthcare team, setting a practical framework to improve the quality of medical care in TBRI Hospital, were generated...
June 2016: Journal of the Egyptian Public Health Association
Kathryn H Bowles, Sarah Ratcliffe, Sheryl Potashnik, Maxim Topaz, John Holmes, Nai-Wei Shih, Mary D Naylor
BACKGROUND: Eliciting knowledge from geographically dispersed experts given their time and scheduling constraints, while maintaining anonymity among them, presents multiple challenges. OBJECTIVES: Describe an innovative, Internet based method to acquire knowledge from experts regarding patients who need post-acute referrals. Compare, 1) the percentage of patients referred by experts to percentage of patients actually referred by hospital clinicians, 2) experts' referral decisions by disciplines and geographic regions, and 3) most common factors deemed important by discipline...
2016: Applied Clinical Informatics
S V Ramanan, Kedar Radhakrishna, Abijeet Waghmare, Tony Raj, Senthil P Nathan, Sai Madhukar Sreerama, Sriram Sampath
Electronic Health Record (EHR) use in India is generally poor, and structured clinical information is mostly lacking. This work is the first attempt aimed at evaluating unstructured text mining for extracting relevant clinical information from Indian clinical records. We annotated a corpus of 250 discharge summaries from an Intensive Care Unit (ICU) in India, with markups for diseases, procedures, and lab parameters, their attributes, as well as key demographic information and administrative variables such as patient outcomes...
August 2016: Journal of Medical Systems
Anne Kuusisto, Paula Asikainen, Kaija Saranto
In this study the development needs of Electronic Nursing Discharge summaries (ENDS) mentioned by nursing professionals are classified and addressed using the FITT model ("Fit between Individuals, Task and Technology") framework.
2016: Studies in Health Technology and Informatics
Zhi Qu, Lue Ping Zhao, Xiemin Ma, Siyan Zhan
BACKGROUND There is increasing interest in clinical research with electronic medical data, but it often faces the challenges of heterogeneity between hospitals. Our objective was to develop a single numerical score for characterizing such heterogeneity via computing inpatient mortality in treating acute myocardial infarction (AMI) patients based on diagnostic information recorded in the database of Discharge Summary Reports (DSR). MATERIAL AND METHODS Using 4 216 135 DSRs of 49 tertiary hospitals from 2006 to 2010 in Beijing, more than 200 secondary diagnoses were identified to develop a risk score for AMI (n=50 531)...
2016: Medical Science Monitor: International Medical Journal of Experimental and Clinical Research
Linda Velta Graudins, Jenny Ly, Jason Trubiano, Ar Kar Aung
AIMS: To determine the gaps in practice regarding appropriate ADR documentation and risk communication for patients diagnosed with severe cutaneous adverse drug reactions (CADR). METHODS: This was a retrospective observational cohort study conducted using hospital coding and databases to identify inpatients diagnosed with CADR from January 2004 to August 2014. Hospital discharge summaries, ADR reports and pharmacy dispensing records were reviewed for ADR documentation...
October 2016: British Journal of Clinical Pharmacology
Christopher A March, Gretchen Scholl, Renee K Dversdal, Matthew Richards, Leah M Wilson, Vishnu Mohan, Jeffrey A Gold
Background With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training. Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes...
May 2016: Journal of Graduate Medical Education
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