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Medical record audit

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https://www.readbyqxmd.com/read/28221255/royal-college-of-ophthalmologists-national-database-study-of-vitreoretinal-surgery-report-7-intersurgeon-variations-in-primary-rhegmatogenous-retinal-detachment-failure
#1
Ahmed B Sallam, Paul H J Donachie, David Yorston, David H W Steel, Tom H Williamson, Timothy L Jackson, John M Sparrow, Robert L Johnston
BACKGROUND/PURPOSE: To audit variations in primary rhegmatogenous retinal detachment (RD) anatomical failure rates between surgeons, grades of surgeons, and techniques of RD surgery. METHODS: Clinical data of a total of 5,857 eyes undergoing primary RD surgery, from 2000 to 2013 were retrospectively extracted from 15 centers using the same commercially available electronic medical record system, from three vitreoretinal units using an in-house electronic medical record, and from the British and Eire Association of Vitreoretinal Surgeons online registry...
February 17, 2017: Retina
https://www.readbyqxmd.com/read/28215132/physiological-antecedents-and-ward-clinician-responses-before-medical-emergency-team-activation
#2
Stephanie K Sprogis, Judy Currey, Julie Considine, Ian Baldwin, Daryl Jones
OBJECTIVES: To investigate the frequency, characteristics and timing of objectively measured clinical instability in adult ward patients in the 24 hours preceding activation of the medical emergency team (MET). We also examined ward clinician responses to documented clinical instability. DESIGN, SETTING AND PARTICIPANTS: A descriptive, exploratory design with a retrospective medical record audit. We descriptively analysed data from 200 ward patients reviewed by the MET at a tertiary teaching hospital in Melbourne, Australia, during 2014...
March 2017: Critical Care and Resuscitation: Journal of the Australasian Academy of Critical Care Medicine
https://www.readbyqxmd.com/read/28211060/shifting-gears-an-inpatient-medical-record-audit-and-post-discharge-survey-of-return-to-driving-following-stroke-transient-ischaemic-attack
#3
Janet Frith, Helen Warren-Forward, Isobel Hubbard, Carole James
BACKGROUND/AIM: In Australia, all stroke survivors should not drive for four weeks and transient ischaemic attack (TIA) survivors should not drive for two weeks. This study investigates the provision of return-to-driving education in the acute hospital setting and the use of this education by a cohort of Australian patients who have experienced a mild stroke or TIA and who are discharged directly home from their acute hospital admission. METHODS: A medical record audit was conducted of stroke patients discharged home from a regional hospital in Australia...
February 16, 2017: Australian Occupational Therapy Journal
https://www.readbyqxmd.com/read/28208186/comparison-of-patient-report-and-medical-records-of-comorbidities-results-from-a-population-based-cohort-of-patients-with-prostate-cancer
#4
Fan Ye, Dominic H Moon, William R Carpenter, Bryce B Reeve, Deborah S Usinger, Rebecca L Green, Kiayni Spearman, Nathan C Sheets, Kevin A Pearlstein, Angela R Lucero, Mark R Waddle, Paul A Godley, Ronald C Chen
Importance: The comorbid conditions of patients with cancer affect treatment decisions, which in turn affect survival and health-related quality-of-life outcomes. Comparative effectiveness research studies must account for these conditions via medical record abstraction or patient report. Objective: To examine the agreement between medical records and patient reports in assessing comorbidities. Design, Setting, and Participants: Patient-reported information and medical records were prospectively collected as part of the North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study, a population-based cohort of 881 patients with newly diagnosed localized prostate cancer enrolled in the North Carolina Central Cancer Registry from January 1, 2011, through June 30, 2013...
February 16, 2017: JAMA Oncology
https://www.readbyqxmd.com/read/28188116/the-importance-of-paper-records-and-their-preservation-period-in-a-central-sterile-supply-department-an-experience-from-a-oncology-center-in-eastern-india
#5
Debabrata Basu, Subhas Chandra Bag, Arijit Das, John Debdutta Razario
Everywhere recordkeeping is very essential for future need. This may be required for any audit purposes, legal issues and forgetting any incident. Record keeping is a specialized area in every hospital that is handled by specialized medical records officer for proper management of all important documents for long time preservation purposes. In this article there are various important healthcare sterilization related paper records have been discussed for documentation and preservation purposes. Though several articles on 'retention of medical records' have already been published worldwide but exclusively sterilization related records and their cause of preservation have not been discussed as such...
February 7, 2017: Journal of Infection and Public Health
https://www.readbyqxmd.com/read/28184317/adherence-to-medication-in-the-community-audit-cycle-of-interventions-to-improve-the-assessment-of-adherence
#6
REVIEW
Saeed Farooq, Abid Choudry
Aims and method To investigate whether medication adherence is monitored during follow-up in out-patient reviews. A retrospective audit was carried out with a sample of 50 follow-up patients with a diagnosis of schizophrenia or schizoaffective disorder. Following this, interventions were made prior to the re-audit (including text messaging clinicians and prompt sheets in the out-patient department to encourage adherence discussions). Results There was an improvement on all the standards set for this audit following the interventions...
February 2017: BJPsych Bulletin
https://www.readbyqxmd.com/read/28183240/pharmacotherapy-of-persons-with-dementia-in-long-term-care-in-australia-a-descriptive-audit-of-central-nervous-system-medications
#7
Wendy Moyle, Najwan El Saifi, Brian Draper, Cindy Jones, Elizabeth Beattie, David Shum, Lukman Thalib, Cindy Mervin, Siobhan O Dwyer
BACKGROUND: Neuropsychiatric symptoms of dementia are often treated through the prescription of one or more psychotropic medications. However, limited efficacy and potential harmful side-effects has resulted in efforts to reduce the use of psychotropic medication in this population, particularly for those living in long-term care. OBJECTIVES: This study sought to describe the pattern of central nervous system medication usage in older adults with dementia living in long-term care; assess the appropriateness of prescribing against Beers criteria; and detect potential drug interactions from co-administered medications...
February 9, 2017: Current Drug Safety
https://www.readbyqxmd.com/read/28182155/clinical-audit-of-copd-in-outpatient-respiratory-clinics-in-spain-the-epoconsul-study
#8
Myriam Calle Rubio, Bernardino Alcázar Navarrete, Joan B Soriano, Juan J Soler-Cataluña, José Miguel Rodríguez González-Moro, Manuel E Fuentes Ferrer, José Luis López-Campos
BACKGROUND: Chronic obstructive pulmonary disease (COPD) outpatients account for a large burden of usual care by respirologists. EPOCONSUL is the first national clinical audit conducted in Spain on the medical care for COPD patients delivered in outpatient respiratory clinics. We aimed to evaluate the clinical interventions and the degree of adherence to recommendations in outpatients of current COPD clinical practice guidelines. METHODOLOGY: This is an observational study with prospective recruitment (May 2014-May 2015) of patients with a COPD diagnosis as seen in outpatient respiratory clinics...
2017: International Journal of Chronic Obstructive Pulmonary Disease
https://www.readbyqxmd.com/read/28173823/effectiveness-of-a-clinical-practice-change-intervention-in-increasing-the-provision-of-nicotine-dependence-treatment-in-inpatient-psychiatric-facilities-an-implementation-trial
#9
Paula M Wye, Emily A Stockings, Jenny A Bowman, Chris Oldmeadow, John H Wiggers
BACKGROUND: Despite clinical practice guidelines recommending the routine provision of nicotine dependence treatment to smokers in inpatient psychiatric facilities, the prevalence of such treatment provision is low. The aim of this study was to examine the effectiveness of a clinical practice change intervention in increasing clinician recorded provision of nicotine dependence treatment to patients in inpatient psychiatric facilities. METHODS: We undertook an interrupted time series analysis of nicotine dependence treatment provision before, during and after a clinical practice change intervention to increase clinician recorded provision of nicotine dependence treatment for all hospital discharges (aged >18 years, N = 4175) over a 19 month period in two inpatient adult psychiatric facilities in New South Wales, Australia...
February 7, 2017: BMC Psychiatry
https://www.readbyqxmd.com/read/28165764/gravity-assisted-valve-gav-systems-to-prevent-low-pressure-headaches-in-patients-with-lumboperitoneal-shunts
#10
Mohammed Akbar Hussain, Roger David Strachan
OBJECTIVES: Low-pressure symptoms after lumboperitoneal (LP) shunting for idiopathic intracranial hypertension (IIH) remain a significant problem. Gravity-assisted valves (GAV) operate at a higher pressure in a vertical position and therefore aim to reduce postural over-drainage. We audited patients with GAV valves inserted in their shunt system to assess their efficacy in reducing low-pressure symptoms and ascertain whether the additional cost of such device can be justified. METHOD: Using a standard proforma, we reviewed patient medical notes and recorded indications and post-operative outcomes in symptom control...
February 6, 2017: British Journal of Neurosurgery
https://www.readbyqxmd.com/read/28157063/safe-excipient-exposure-in-neonates-and-small-children-protocol-for-the-seen-project
#11
Kristine Svinning Valeur, Steen Axel Hertel, Kaare Engell Lundstrøm, Helle Holst
INTRODUCTION: The pharmacokinetics of excipients in neonates differs from that of older children. In a recent pan--European survey, two thirds of neonates received at least one potentially harmful excipient, such as ethanol and benzoates. The content of sweeteners varied by route of administration (more common by enteral than parenteral route), and regional differences were revealed. The survey did not identify if the content of excipients was more pronounced in medications prescribed for specific medical diseases, e...
February 2017: Danish Medical Journal
https://www.readbyqxmd.com/read/28152900/hardwiring-advance-directives-into-an-electronic-medical-record
#12
Tyler Buckley, Andrew Badke, Amy Horyna, Julie Howell, Lisa Gren, Anna Catherine Beck
: 146 Background: Patient preference at the end of life has been extensively researched and documented. Advance Directives (AD) have been shown to make a difference for patients in the areas of quality, cost, and patient satisfaction. Organizations struggle with meeting federal laws and accreditation expectations due to our complex systems. Literature supports "hardwiring" AD documentation into the EMR and providing "one click" accessibility to AD's. Changing EMR vendors provides a unique opportunity to optimize access to AD's, both through patient education /endorsement, review of providers' role, and engagement of IT...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28152868/compliance-with-national-comprehensive-cancer-network-guidelines-for-antiemesis-in-cisplatin-regimens
#13
Dana Ann Little
: 280 Background: The members of a network of community cancer centers affiliated with an academic medical center report following National Comprehensive Cancer Network (NCCN) guidelines. To determine guideline compliance, cisplatin regimens were audited. Cisplatin was selected because of its wide use, high emetic potential, and the impact on QOL for patients with unmanaged nausea and vomiting.The community cancer centers affiliated with an academic medical center report following National Comprehensive Cancer Network (NCCN) guidelines for treatment plans...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28152824/treatment-prices-at-the-point-of-care-pilot
#14
Rebecca W Lau, Leah Tuzzio, Matthew Alan Christianson, Eric Y Chen, Thanh-Hien Phan
: 4 Background: People with cancer increasingly wish to discuss cancer care costs with clinicians. In our organization all price questions go to a central customer service line with limited capacity to address oncology-specific questions. We aimed to improve clinician access to treatment prices to assist them in responding to patient concerns about prices. METHODS: We developed, launched, and evaluated a pilot tool and accompanying workflow for four oncology clinics in an integrated delivery system in WA...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28152712/application-of-a-standard-practice-based-system-to-measure-and-compare-quality-of-cancer-survivorship-care
#15
Katherine Ramsey Gilmore, Patricia Chapman, Paula A Lewis-Patterson, Maria Alma Rodriguez
: 239 Background: Despite the growing committment to improve survivorship care, measuring its quality remains difficult. In 2006, the American Society of Clinical Oncologists (ASCO) launched a practice-based system known as the Quality Oncology Practice Initiative (QOPI) to measure the quality of cancer care. Here, we demonstrate the use of QOPI procedures to compare compliance with survivorship care plans (SCPs) across different disease-specific clinics. METHODS: Measures based on survivorship clinical practice guidelines were abstracted from SCPs issued to survivors scheduled for appointments in site-specific clinics...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28151385/transfusion-associated-circulatory-overload-in-adult-medical-emergency-patients-with-perspectives-on-early-warning-practice-a-single-centre-clinical-study
#16
Fanny Gosmann, Astrid Nørgaard, Maj-Britt Rasmussen, Charlotte Rahbek, Jens Seeberg, Tom Møller
BACKGROUND: Transfusion-associated circulatory overload is characterised by acute respiratory distress, tachycardia, increased blood pressure, acute pulmonary oedema and/or evidence of positive fluid balance occurring within 6 hours after transfusion. Transfusion-associated circulatory overload is a serious, underreported reaction, which makes this iatrogenic condition difficult to prevent. We present an audit of patients admitted to a medical emergency unit, aiming to investigate: (i) the incidence of transfusion-associated circulatory overload; and (ii) whether cases were reported to the haemovigilance system...
January 26, 2017: Blood Transfusion, Trasfusione del Sangue
https://www.readbyqxmd.com/read/28147212/advance-care-directive-documentation-issues-for-clinicians-in-new-south-wales
#17
Mark I Friedewald, Peter A Cleasby
Objective The aim of the present study was to assess the characteristics of documents presented as advance care directives (ACDs) at a public health organisation in New South Wales (NSW). It was envisaged that the findings would inform the refinement of locally developed educational strategies.Methods All ACD documents provided during hospital admissions and entered into the electronic medical record system over a 12-month period were reviewed. An audit tool was developed and used to identify whether key requirements for ACDs in NSW had been addressed...
February 2, 2017: Australian Health Review: a Publication of the Australian Hospital Association
https://www.readbyqxmd.com/read/28132009/challenges-in-data-quality-the-influence-of-data-quality-assessments-on-data-availability-and-completeness-in-a-voluntary-medical-male-circumcision-programme-in-zimbabwe
#18
Y Xiao, A F Bochner, B Makunike, M Holec, S Xaba, M Tshimanga, V Chitimbire, S Barnhart, C Feldacker
OBJECTIVES: To assess availability and completeness of data collected before and after a data quality audit (DQA) in voluntary medical male circumcision (VMMC) sites in Zimbabwe to determine the effect of this process on data quality. SETTING: 4 of 10 VMMC sites in Zimbabwe that received a DQA in February, 2015 selected by convenience sampling. PARTICIPANTS: Retrospective reviews of all client intake forms (CIFs) from November, 2014 and May, 2015...
January 27, 2017: BMJ Open
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/28118917/opening-the-duke-electronic-health-record-to-apps-implementing-smart-on-fhir
#20
Richard A Bloomfield, Felipe Polo-Wood, Joshua C Mandel, Kenneth D Mandl
OBJECTIVE: Recognizing a need for our EHR to be highly interoperable, our team at Duke Health enabled our Epic-based electronic health record to be compatible with the Boston Children's project called Substitutable Medical Apps and Reusable Technologies (SMART), which employed Health Level Seven International's (HL7) Fast Healthcare Interoperability Resources (FHIR), commonly known as SMART on FHIR. METHODS: We created a custom SMART on FHIR-compatible server infrastructure written in Node...
March 2017: International Journal of Medical Informatics
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