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Medical record audit

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https://www.readbyqxmd.com/read/29157196/perinatal-outcomes-of-hypertensive-disorders-in-pregnancy-at-a-tertiary-hospital-in-ghana
#1
Kwame Adu-Bonsaffoh, Michael Y Ntumy, Samuel A Obed, Joseph D Seffah
BACKGROUND: Hypertensive disorders in pregnancy remain a major global health issue not only because of the associated high adverse maternal outcomes but there is a close accompaniment of significant perinatal morbidity and mortality especially in Sub-Saharan Africa (SSA). However, the perinatal burden of HDP in Ghana has not been explored. We conducted this study to determine the perinatal outcomes of HDP at a tertiary hospital in Ghana. METHODS: A cross-sectional study conducted between January to February 2013 at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana...
November 21, 2017: BMC Pregnancy and Childbirth
https://www.readbyqxmd.com/read/29149456/effect-of-a-thermal-care-bundle-on-the-prevention-detection-and-treatment-of-perioperative-inadvertent-hypothermia
#2
Jed Duff, Kim Walker, Karen-Leigh Edward, Nicholas Ralph, Jo-Ann Giandinoto, Kimberley Alexander, Jeffrey Gow, John Stephenson
AIMS AND OBJECTIVES: To improve the prevention, detection, and treatment of perioperative inadvertent hypothermia (PIH) in adult surgical patients by implementing a Thermal Care Bundle. BACKGROUND: Keeping patients normothermic perioperatively prevents adverse surgical outcomes. Hypothermia leads to serious complications including increased risk of surgical bleeding, surgical site infections, and morbid cardiac events. The Thermal Care Bundle consists of three elements: 1) assess risk; 2) record temperature; and (3) actively warm...
November 17, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/29148172/quality-of-handwritten-surgical-operative-notes-from-surgical-trainees-a-noteworthy-issue
#3
Tatenda C Nzenza, Todd Manning, Simeon Ngweso, Marlon Perera, Shomik Sengupta, Damien Bolton, Nathan Lawrentschuk
BACKGROUND: Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met...
November 17, 2017: ANZ Journal of Surgery
https://www.readbyqxmd.com/read/29137585/association-of-positive-fluid-balance-and-mortality-in-sepsis-and-septic-shock-in-an-australian-cohort
#4
M G Pittard, S J Huang, A S McLean, S R Orde
In patients with septic shock, a correlation between positive fluid balance and worsened outcomes has been reported in multiple observational studies worldwide. No published data exists in an Australasian cohort. We set out to explore this association in our institution. We conducted a retrospective audit of patient records from August 2012 to May 2015 in a single-centre, 24-bed surgical and medical intensive care unit (ICU) in Sydney, Australia. All patients with septic shock were included. Exclusion criteria included length of stay less than 24 hours or vasopressors needed for less than six hours...
November 2017: Anaesthesia and Intensive Care
https://www.readbyqxmd.com/read/29135754/implementation-of-a-pediatric-behavioral-staffing-algorithm-in-an-acute-hospital-a-best-practice-implementation-project
#5
Tamara O'Connor
BACKGROUND: A progressive decline in acute psychiatric facility beds has led to a steadily increasing number of pediatric psychiatric patients hospitalized on acute care medical-surgical units. Clinical nurses in this environment feel ill-equipped to provide quality behavioral health care. AIMS/OBJECTIVES: This project aimed to improve continuity of care as well as staff and patient safety in pediatric acute and transitional care units. The specific objectives related to implementation of a resource allocation algorithm for staffing behavioral health admissions and consistent use of an interdisciplinary psychiatric huddle...
November 2017: JBI Database of Systematic Reviews and Implementation Reports
https://www.readbyqxmd.com/read/29134926/influence-of-stroke-coordinators-on-delivery-of-acute-stroke-care-and-hospital-outcomes-an-observational-study
#6
Tara Purvis, Monique F Kilkenny, Sandy Middleton, Dominique A Cadilhac
Background Stroke coordinators have been inconsistently used in various countries to support stroke care in hospital. Aim To investigate the association between stroke coordinators and the provision of evidence-based care and patient outcomes in hospitals with acute stroke units. Methods Observational study using cross-sectional data from the 2015 National Acute Services Audit Program (Australia): including a retrospective medical record audit (40 records from each hospital) and a self-reported survey of organizational resources for stroke...
January 1, 2017: International Journal of Stroke: Official Journal of the International Stroke Society
https://www.readbyqxmd.com/read/29124913/measurement-of-lying-and-standing-blood-pressure-in-hospital
#7
Shelagh O'Riordan, Naomi Vasilakis, Labib Hussain, Rowena Schoo, Julie Whitney, Julie Windsor, Khim Horton, Finbarr Martin
Measuring lying and standing blood pressure (BP) is an important clinical observation in older hospital inpatients. This is because a drop in BP on standing, known as orthostatic hypotension (OH) is common in older people and in acute illness and, therefore, in hospital patients. OH increases the risk of a fall in hospital. Simple measures such as changes in medication or rehydration can reduce this drop in BP and reduce the risk of falls. In a recent snapshot audit in England and Wales of 179 acute hospitals and 4,846 patients aged 65 years and over admitted with an acute illness, only 16% had a lying and standing BP recorded within 48 hours...
September 29, 2017: Nursing Older People
https://www.readbyqxmd.com/read/29121175/association-of-the-presence-of-trainees-with-outpatient-appointment-times-in-an-ophthalmology-clinic
#8
Isaac H Goldstein, Michelle R Hribar, Sarah Read-Brown, Michael F Chiang
Importance: Physicians face pressure to improve clinical efficiency, particularly with electronic health record (EHR) adoption and gradual shifts toward value-based reimbursement models. These pressures are especially pronounced in academic medical centers, where delivery of care must be balanced with medical education. However, the association of the presence of trainees with clinical efficiency in outpatient ophthalmology clinics is not known. Objective: To quantify the association of the presence of trainees (residents and fellows) and efficiency in an outpatient ophthalmology clinic...
November 9, 2017: JAMA Ophthalmology
https://www.readbyqxmd.com/read/29120878/investigating-the-effects-of-under-triage-by-existing-major-incident-triage-tools
#9
James M Vassallo, Jason E Smith, Lee A Wallis
OBJECTIVES: Triage is a key principle in the effective management of a major incident. Its effectiveness is a balance between identifying those in need of life-saving intervention, and those triaged incorrectly as either needing/not needing life-saving intervention. The primary aim of this study was to report mortality in those under-triaged by existing major incident triage tools. Secondary aims were to report the ability of triage tools at identifying serious injury by body region (defined as the Abbreviated Injury Scale≥3)...
November 8, 2017: European Journal of Emergency Medicine: Official Journal of the European Society for Emergency Medicine
https://www.readbyqxmd.com/read/29110295/prevalence-and-variability-in-medications-contributing-to-polypharmacy-in-long-term-care-facilities
#10
Natali Jokanovic, Kris M Jamsen, Edwin C K Tan, Michael J Dooley, Carl M Kirkpatrick, J Simon Bell
BACKGROUND: Research into which medications contribute to polypharmacy and the variability in these medications across long-term care facilities (LTCFs) has been minimal. OBJECTIVE: Our objective was to investigate which medications were more prevalent among residents with polypharmacy and to determine the variability in prescribing of these medications across LTCFs. METHODS: This was a cross-sectional study of 27 LTCFs in regional and rural Victoria, Australia...
December 2017: Drugs—Real World Outcomes
https://www.readbyqxmd.com/read/29107565/rubber-stamp-templates-for-improving-clinical-documentation-a-paper-based-m-health-approach-for-quality-improvement-in-low-resource-settings
#11
Bernadette Kleczka, Anita Musiega, Grace Rabut, Phoebe Wekesa, Paul Mwaniki, Michael Marx, Pratap Kumar
BACKGROUND: The United Nations' Sustainable Development Goal #3.8 targets 'access to quality essential healthcare services'. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones...
October 23, 2017: International Journal of Medical Informatics
https://www.readbyqxmd.com/read/29104769/does-audit-and-feedback-improve-the-adoption-of-recommended-practices-evidence-from-a-longitudinal-observational-study-of-an-emerging-clinical-network-in-kenya
#12
Susan Gachau, Philip Ayieko, David Gathara, Paul Mwaniki, Morris Ogero, Samuel Akech, Michuki Maina, Ambrose Agweyu, Jacqiue Oliwa, Thomas Julius, Lucas Malla, James Wafula, George Mbevi, Grace Irimu, Mike English
Background: Audit and feedback (A&F) is widely used in healthcare but there are few examples of how to deploy it at scale in low-income countries. Establishing the Clinical Information Network (CIN) in Kenya provided an opportunity to examine the effect of A&F delivered as part of a wider set of activities to promote paediatric guideline adherence. Methods: We analysed data collected from medical records on discharge for children aged 2-59 months from 14 Kenyan hospitals in the CIN...
2017: BMJ Global Health
https://www.readbyqxmd.com/read/29101924/the-challenge-of-liver-cancer-surveillance-in-general-practice-do-recall-and-reminder-systems-hold-the-answer
#13
Nicole Allard, Tracey Cabrie, Emily Wheeler, Jacqui Richmond, Jennifer MacLachlan, Jon Emery, John Furler, Benjamin Cowie
BACKGROUND: Hepatocellular carcinoma (HCC) surveillance reduces mortality in at-risk people living with chronic hepatitis B (CHB), but is difficult to achieve in practice. The objective of this study was to measure participation and adherence to liver cancer HCC surveillance in eligible patients in a community health centre, following support from the Integrated Hepatitis B Service (IHBS). METHODS: A retrospective analysis of the medical records of patients with CHB who met the indications for HCC surveillance over a 4...
November 2017: Australian Family Physician
https://www.readbyqxmd.com/read/29101617/quality-of-medication-information-in-discharge-summaries-from-hospitals-an-audit-of-electronic-patient-records
#14
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
https://www.readbyqxmd.com/read/29101478/auditing%C3%A2-the-completeness-and-legibility-of%C3%A2-computerized%C3%A2-radiological-request-forms
#15
Yahya Al Muallem, Majed Al Dogether, Mowafa Househ, Basema Saddik
Certain Saudi healthcare organizations transfer outpatients to medical imaging departments for radiological examinations in a manual process that relies on the use of paper-based forms. With the increased implementation of electronic medical records in Saudi Hospitals, little is known about the completeness and legibility of information captured in  electronic-based medical imaging forms. The purpose of this study is to audit the completeness and legibility of medical imaging paper-based forms in comparison with electronic-based medical imaging forms...
November 4, 2017: Journal of Medical Systems
https://www.readbyqxmd.com/read/29101142/protocol-for-a-national-prevalence-study-of-advance-care-planning-documentation-and-self-reported-uptake-in-australia
#16
Rasa Ruseckaite, Karen M Detering, Sue M Evans, Veronica Perera, Lynne Walker, Craig Sinclair, Josephine M Clayton, Linda Nolte
INTRODUCTION: Advance care planning (ACP) is a process between a person, their family/carer(s) and healthcare providers that supports adults at any age or stage of health in understanding and sharing their personal values, life goals and preferences regarding future medical care. The Australian government funds a number of national initiatives aimed at increasing ACP uptake; however, there is currently no standardised Australian data on formal ACP documentation or self-reported uptake...
November 3, 2017: BMJ Open
https://www.readbyqxmd.com/read/29098731/clues-for-early-detection-of-autoimmune-addison-s-disease-myths-and-realities
#17
Å B Saevik, A-K Åkerman, K Grønning, I Nermoen, S F Valland, T E Finnes, M Isaksson, P Dahlqvist, R Bergthorsdottir, O Ekwall, J Skov, B G Nedrebø, A-L Hulting, J Wahlberg, J Svartberg, C Höybye, I H Bleskestad, A P Jørgensen, O Kämpe, M Øksnes, S Bensing, E S Husebye
BACKGROUND: Early detection of autoimmune Addison's disease (AAD) is important as delay in diagnosis may result in a life-threatening adrenal crisis and death. The classical clinical picture of untreated AAD is well-described, but methodical investigations are scarce. OBJECTIVE: Perform a retrospective audit of patient records with the aim of identifying biochemical markers for early diagnosis of AAD. MATERIAL AND METHODS: A multicentre retrospective study including 272 patients diagnosed with AAD at hospitals in Norway and Sweden during 1978-2016...
November 3, 2017: Journal of Internal Medicine
https://www.readbyqxmd.com/read/29082725/upcoming-strategies-in-obstetrics-how-the-technology-of-clinical-audit-may-reduce-cesarean-birth
#18
Sara Paracchini, Bianca Masturzo, Domenico Tangolo, Enrica Roletti, Annalisa Piazzese, Rossella Attini, Alessandro Rolfo, Tullia Todros
BACKGROUND: The rate of cesarean delivery is currently increasing all over Europe. In Italy it reaches 38% of all child births. Therefore, it is important to identify the clinical and organizational variables that determine the appropriateness of elective cesarean delivery. With this aim we chose the technology of clinical audit, a process that promotes improvement in clinical practice through systematic review of clinical care in relation with explicit standards derived from scientific literature...
December 2017: Minerva Ginecologica
https://www.readbyqxmd.com/read/29077713/clinical-spectrum-of-pseudoexfoliation-syndrome-an-electronic-records-audit
#19
Aparna Rao, Debananda Padhy, Prity Sahay, Amiya Pradhan, Sarada Sarangi, Gopinath Das, Niranjan Raj
PURPOSE: To evaluate different clinical variants of pseudoexfoliation syndrome and their risk of developing ocular hypertension (OHT) or glaucoma (PXG). DESIGN: Cross sectional hospital based study. SETTING: All patients seen at glaucoma services of a tertiary eye care center in east India. METHODS: Electronic medical records search of hospital database including consecutive new and old cases seen during April 2013 to March 2015 was done to retrieve case sensitive words including pseudoexfoliation, PXF, PEX, PXG and pseudoexfoliative glaucoma over any part of the clinical electronic sheet of the patient...
2017: PloS One
https://www.readbyqxmd.com/read/29054575/emergency-department-presentations-by-older-people-for-mental-health-or-drug-and-alcohol-conditions-a-multicentre-retrospective-audit
#20
Margaret Fry, Steve Kay, Rosalind M Elliott
PURPOSE: Emergency department presentations by older people associated with mental health and drug and alcohol related conditions are increasing. However, the characteristics of presentations by older people in Australia are largely unknown. The aim of this research was to explore the characteristics of older people presenting with mental health and drug and alcohol conditions. PROCEDURES: We used a retrospective electronic medical record audit to explore all emergency department presentations by older people 65 years and over for mental health and drug and alcohol related conditions over a 12 month period...
October 17, 2017: Australasian Emergency Nursing Journal: AENJ
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