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Medical record audit

Olivia Farrer, Alison Yaxley, Karen Walton, Michelle Miller
AIM: The prevalence of diabetes in older adults in residential aged care (RAC) is twice that of community dwelling older adults. Older adults with diabetes have been highlighted as being at high risk of frailty and malnutrition, particularly when managed on a therapeutic diet. However, assumptions may be based on clinical presentation of our oldest old which may be at conflict with the clinical presentation of younger older adults. The aim of this retrospective audit was to identify the characteristics of aged care residents with diabetes, their comorbidities and malnutrition risk...
March 15, 2018: Nutrition & Dietetics: the Journal of the Dietitians Association of Australia
Clodoaldo Tentes Côrtes, Sonia Maria Junqueira Vasconcellos de Oliveira, Rafael Cleison Silva Dos Santos, Adriana Amorim Francisco, Maria Luiza Gonzalez Riesco, Gilceria Tochika Shimoda
OBJECTIVE: to evaluate the impact of the implementation of evidence-based practices on normal delivery care. METHOD: quasi-experimental, before-and-after intervention study conducted in a public maternity hospital, Amapá. Forty-two professionals and 280 puerperal women were interviewed and data from 555 medical records were analyzed. The study was developed in three phases: baseline audit (phase 1), educational intervention (phase 2) and post-intervention audit (phase 3)...
March 8, 2018: Revista Latino-americana de Enfermagem
Heather C Kaplan, Eileen King, Beth E White, Susan E Ford, Sandra Fuller, Michael A Krew, Michael P Marcotte, Jay D Iams, Jennifer L Bailit, Jo M Bouchard, Kelly Friar, Carole M Lannon
OBJECTIVE: To evaluate the success of a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data accuracy rapidly and at scale in Ohio. METHODS: Between February 2013 and March 2014, participating hospitals were involved in a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data. This initiative was designed as a learning collaborative model (group webinars and a single face-to-face meeting) and included individual quality improvement coaching...
March 8, 2018: Obstetrics and Gynecology
Liz Floyd, Fiona Bryce, Rohit Ramaswamy, Adeyemi Olufolabi, Emmanuel Srofenyoh, David Goodman, Nancy Pearson, Kerry Morgan, Cecilia Tetteh, Victoria Ahwireng, Medge Owen
OBJECTIVE: to introduce and embed a midwife-led obstetric triage system in a busy labour ward in Accra, Ghana to improve the quality of care and to reduce delay. DESIGN: the study utilized a participatory action research design. Local staff participated in baseline data collection, the triage training course design and delivery, and post-training monitoring and evaluation. SETTING: a regional referral hospital in Accra, Ghana undertaking 11,032 deliveries in 2012...
February 12, 2018: Midwifery
Francisco Jesús Represas Carrera, Álvaro Carrera García, Ana Clavería Fontán
OBJECTIVE: Type 2 Diabetes Mellitus is a chronic disease that represent an important problem of public health. The objective of this study was to describe the sociodemographic, anthropometric, metabolic control, comorbidity and cardiovascular risk characteristics of patients diagnosed with Diabetes Mellitus type 2 in the health area of Vigo. METHODS: Retrospective observational descriptive study. Between March and September 2016, it did telephone interview and an audit of electronic medical records to 195 patients ≥ 18 years old from the health area of Vigo diagnosed with type 2 Diabetes Mellitus...
March 9, 2018: Revista Española de Salud Pública
Derek J Chan, Virginia Furner, Don E Smith, Mithilesh Dronavalli, Rohan I Bopage, Jeffrey J Post, Anjali K Bhardwaj
OBJECTIVE: To assess the prevalence of non-AIDS co-morbidities (NACs) and predictors of adverse health outcomes amongst people living with HIV in order to identify health needs and potential gaps in patient management. DESIGN: Retrospective, non-consecutive medical record audit of patients attending a publicly funded HIV clinic in metropolitan Sydney analysed for predictors of adverse health outcomes. We developed a scoring system based on the validated Charlson score method for NACs, mental health and social issues and confounders were selected using directed acyclic graph theory under the principles of causal inference...
March 8, 2018: AIDS Research and Therapy
Deepti Shanbhag, Ian D Graham, Karen Harlos, R Brian Haynes, Itzhak Gabizon, Stuart J Connolly, Harriette Gillian Christine Van Spall
BACKGROUND: The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. METHODS: We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction...
March 6, 2018: BMJ Open
Masaaki Ishibashi, Masakazu Ishii, Miku Nagano, Yuji Kiuchi, Sanju Iwamoto
 Previous reports suggested that sharing outpatient information during chemotherapy is very important for managing pharmaceutical usage between community pharmacies and hospitals. We herein examined using a questionnaire survey whether pharmaceutical management for outpatient chemotherapy is desired by community and hospital pharmacists. The response rates were 44.3% (133/300) for pharmacists in community pharmacies and 53.7% (161/300) for pharmacists in hospitals. Prescriptions for outpatients during chemotherapy were issued at 88...
2018: Yakugaku Zasshi: Journal of the Pharmaceutical Society of Japan
Christopher King, Justin C Sherwin, Gokulan Ratnarajan, John F Salmon
BACKGROUND/AIMS: To determine the mortality within 20 years of diagnosis of chronic open-angle glaucoma (COAG) and visual acuity and visual field progression of a cohort followed for 20 years. METHODS: Twenty years following the diagnosis of COAG in 68 of 436 (16%) patients seen in a glaucoma case-finding clinic, visual and mortality outcomes were audited from medical records. Causes of death were obtained from general practitioner records and death certificates...
March 3, 2018: British Journal of Ophthalmology
Melissa C Morgan, Harriet Nambuya, Peter Waiswa, Cally Tann, Diana Elbourne, Janet Seeley, Elizabeth Allen, Joy E Lawn
Background: Kangaroo mother care (KMC) for stable neonates ≤2000 g (g) is associated with decreased mortality, sepsis, hypothermia, and length of stay compared to conventional care. The World Health Organization states that KMC "should be initiated… as soon as newborns are clinically stable " [12]. However, the majority of deaths occur in unstable neonates. We aimed to determine the proportion of admitted neonates meeting proposed instability criteria, assess the feasibility of providing KMC to unstable neonates, and evaluate the acceptability of this intervention to parents and providers at Jinja Regional Referral Hospital in Uganda...
June 2018: Journal of Global Health
Wenqi Hu, Carri W Chan, José R Zubizarreta, Gabriel J Escobar
OBJECTIVE: We sought to build on the template-matching methodology by incorporating longitudinal comorbidities and acute physiology to audit hospital quality. STUDY SETTING: Patients admitted for sepsis and pneumonia, congestive heart failure, hip fracture, and cancer between January 2010 and November 2011 at 18 Kaiser Permanente Northern California hospitals. STUDY DESIGN: We generated a representative template of 250 patients in 4 diagnosis groups...
February 26, 2018: Medical Care
Jennifer Yeung, Anna Stecher, Catrina C Crisp, Donna Mazloomdoost, Benjamin Smith, Steven D Kleeman, Rachel N Pauls
OBJECTIVES: Obstetric anal sphincter injuries (OASISs) are a devastating postpartum complication; reducing rates is paramount to improving quality of care. In Norway, implementation of a perineal protection program decreased the incidence of OASIS by 48%. We sought to assess impact on OASIS rates following a similar program. METHODS: This institutional review board-approved, retrospective cohort study was performed in an academic hospital system. The periods of analysis were November 2014 through October 2015 for the preintervention arm and November 2015 through October 2016 for the postintervention arm...
March 2018: Female Pelvic Medicine & Reconstructive Surgery
D Menon, P G Chelakkot
BACKGROUND: Radiation therapy is a major treatment option in the management of primary central nervous system (CNS) tumors, though recurrences after primary treatment, especially in high-grade glial tumors, is a challenge for treating physician. Advances in the field of radiation have made reirradiation a feasible option in recurrent CNS tumors. MATERIALS AND METHODS: Details of patients with primary CNS lesions who presented between 2009 and 2016, with recurrent CNS lesions, and who were treated with reirradiation were retrieved from electronic medical records, as a departmental audit, and the outcome was analyzed...
April 2017: Indian Journal of Cancer
Cristina López Muñoz, Andrés Sánchez Yagüe, Jose Carlos Canca Sánchez, José Antonio Reinaldo-Lapuerta, Ana Belén Moya Suárez
INTRODUCTION: research has shown that an endoscopist-nurse clinical team can perform sedation with propofol effectively, safely and efficiently. To do so, it is essential to provide specific and appropriate training in the necessary skills. The main aim of the present study was to evaluate the quality of the sedation procedure administered by non-anesthetists in a digestive endoscopy unit, one year after its introduction. METHODS: a prospective cohort study was performed in patients given propofol sedation by non-anesthetists...
February 21, 2018: Revista Española de Enfermedades Digestivas
Z Meidani, M Farzandipour, A Davoodabadi, A Farrokhian, D Kheirkhah, M Sharifi, M E Khanghani
We investigated the effects of reinforced audit and feedback on the medical record documentation (MRD) of 35 surgical residents at a tertiary university hospital. In three phases (pre-intervention, 3 and 9-month post-intervention), 525 medical records were assessed. An educational guideline assisting residents to record more accurate MRD was developed. The MRD rate in the pre-intervention and immediate post-intervention phases had changed significantly. The MRD rate in the pre-intervention and 9 months after cessation of intervention was not statistically significant...
September 2017: Journal of the Royal College of Physicians of Edinburgh
A N Williams, B Mold, L Kilbey, P Naganna
AIMS: To explore 40 years of Child Development Centre (CDC) activity and outcomes at Northampton General Hospital 1974-2014. METHODS: The study comprises 3 data sets: a published report from 1974 to 1999, an internal audit from 2001 to 2004, and more recent data collected from 2005 to 2014. The medical notes of all children who were assessed by the CDC in 2014 were reviewed, along with referral data collected by the CDC manager from this year and the preceding 10 years...
February 20, 2018: Child: Care, Health and Development
Kevin Albuquerque, Kellie Rodgers, Ann Spangler, Asal Rahimi, DuWayne Willett
PURPOSE: The on-treatment visit (OTV) for radiation oncology is essential for patient management. Radiation toxicities recorded during the OTV may be inconsistent because of the use of free text and the lack of treatment site-specific templates. We developed a radiation oncology toxicity recording instrument (ROTOX) in a health system electronic medical record (EMR). Our aims were to assess improvement in documentation of toxicities and to develop clinic toxicity benchmarks. METHODS: A ROTOX that was based on National Cancer Institute Common Terminology Criteria for Adverse Events (version 4...
February 13, 2018: Journal of Oncology Practice
Vincenzo Nuzzo, Tiziana Attardo, Giuseppe Augello, Davide Brancato, Salvatore Camerlingo, Clelia Canale, Federica Coretti, Alessandro Franco, Francesco Giacometti, Maurizio Gambacorta, Massimo Loreno, Ada Maffettone, Vincenzo Provenzano, Alfonso Zuccoli
Audit is a clinical instrument of government characterized by a whole process of evaluation inter pares to improve medical behaviors in the clinical practice. Different endocrinopathies are underestimated in the clinical and diagnostics practice but they can be a real problem in patients admitted in the departments of Internal Medicine. The Adrenal Incidentaloma (AI) is an accidental discovery with an incidence equal to 4% in radiologic studies but it's rarely considereted in the internal disorders. In the departments of Internal Medicine are hospitalized each year approximately 1...
February 13, 2018: Minerva Endocrinologica
Hannah Grace Dahlen, Jann P Foster, Kim Psaila, Kaye Spence, Nadia Badawi, Cathrine Fowler, Virginia Schmied, Charlene Thornton
BACKGROUND: Gastro-oesophageal reflux (GOR) is common in infants. When the condition causes pathological symptoms and/or complications it is considered gastro-oesophageal reflux disease (GORD). It appears to be increasingly diagnosed and causes great distress in the first year of infancy. In New South Wales (NSW), residential parenting services support families with early parenting difficulties. These services report a large number of babies admitted with a label of GOR/GORD. The aim of this study was to explore the maternal and infant characteristics, obstetric interventions, and reasons for clinical reporting of GOR/GORD in NSW in the first 12 months following birth (2000-2011)...
February 12, 2018: BMC Pediatrics
Marcela Colom, Kirsten Austad, Neftali Sacuj, Karen Larson, Peter Rohloff
The utilization of existing social networks is increasingly being recognized as a powerful strategy for delivering healthcare services to underserved populations in low- and middle-income countries. In Guatemala, multiple barriers prevent access to healthcare services for rural and indigenous populations, and strategies for delivering healthcare in more efficient ways are needed. The case study we describe here is a unique collaboration between a microfinance institution (Friendship Bridge) and a primary care organization (Wuqu' Kawoq | Maya Health Alliance) to scale up healthcare through an existing lending-borrowing social network...
February 7, 2018: Healthcare
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