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Medical record audit

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https://www.readbyqxmd.com/read/28320069/usefulness-of-laboratory-and-radiological-investigations-in-the-management-of-supraventricular-tachycardia
#1
Aadith Ashok, Miguel Cabalag, David McD Taylor
OBJECTIVE: Although ED patients presenting with supraventricular tachycardia (SVT) are commonly investigated, the value of these investigations has been questioned. We aimed to determine the frequency and utility of investigations in patients with SVT. METHODS: We undertook an explicit retrospective medical record audit of patients with SVT who presented to a single ED (January 2004 to June 2014). Data on demographics, presenting complaints, investigations and outcomes were extracted...
March 20, 2017: Emergency Medicine Australasia: EMA
https://www.readbyqxmd.com/read/28319416/specifics-in-the-review-of-health-documentation
#2
K Kacalova, B Havelkova, D Farkasova
OBJECTIVES: The objective of the work was to identify if health documentation management is depending of actually current legislation. Also to review range and consistency records. The work described forms and content of documentation, relating to treat wounds and decubitus. METHODS: A content analysis of 139 health documentation of insurer of General Health Insurance Company, which were treated by 28 home care agencies (hereinafter "HCA") and in the HCA was done directly audit in 2012 and 2014...
2017: Bratislavské Lekárske Listy
https://www.readbyqxmd.com/read/28306135/how-common-are-pulmonary-and-hepatic-adverse-effects-in-older-adults-prescribed-nitrofurantoin
#3
Karin Claussen, Edward Stocks, Deepa Bhat, Jason Fish, Craig D Rubin
OBJECTIVES: To determine the frequency of serious pulmonary and hepatic adverse events (AEs) in persons aged 65 and older prescribed nitrofurantoin. DESIGN: Retrospective electronic health record (EHR) audit of nitrofurantoin prescriptions and associated AEs. SETTING: Urban academic medical center. PARTICIPANTS: All inpatients and outpatients aged 65 and older prescribed nitrofurantoin from January 1, 2010, to December 31, 2014...
March 17, 2017: Journal of the American Geriatrics Society
https://www.readbyqxmd.com/read/28300990/analysis-of-the-attributes-of-primary-health-care-using-the-electronic-medical-records-in-the-city-of-rio-de-janeiro
#4
Daniel Soranz, Luiz Felipe Pinto, Luiz Antonio Bastos Camacho
Epidemiology plays a strategic role at this stage of the policy cycle, contributing to goal setting, resource allocation and use of information systems. In 2009, the Municipal Health Secretariat of Rio de Janeiro initiated a reform of the health care model under the main influence the Primary Health Care concept. This study evaluates the trend of selected pay-for-performance indicators that measure the health care process in the city's PHC. This a study on repeated panels, from the administrative and clinical records of electronic medical records in the period from 2012 to 2016...
March 2017: Ciência & Saúde Coletiva
https://www.readbyqxmd.com/read/28288634/understanding-the-implementation-and-adoption-of-a-technological-intervention-to-improve-medication-safety-in-primary-care-a-realist-evaluation
#5
Mark Jeffries, Denham L Phipps, Rachel L Howard, Anthony J Avery, Sarah Rodgers, Darren M Ashcroft
BACKGROUND: Monitoring for potentially hazardous prescribing is increasingly important to improve medication safety. Healthcare information technology can be used to achieve this aim, for example by providing access to prescribing data through surveillance of patients' electronic health records. The aim of our study was to examine the implementation and adoption of an electronic medicines optimisation system that was intended to facilitate clinical audit in primary care by identifying patients at risk of an adverse drug event...
March 14, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/28274343/prevalence-correlates-and-treatment-status-of-alcohol-use-disorders-in-psychiatric-patients-in-china
#6
Hui Huang, Hongxian Chen, Huixi Dong, Kui Ning, Ruiling Zhang, Wei Sun, Bing Li, Haifeng Jiang, Wenzheng Wang, Jiang Du, Min Zhao, Zhihua Yi, Jing Li, Rongxin Zhu, Shuiping Lu, Shiping Xie, Xiaoping Wang, Wei Fu, Runzhi Yan, Chengge Gao, Wei Hao
OBJECTIVE: To determine the prevalence, associated factors and treatment status of alcohol use disorders (AUDs) in psychiatric patients in China. METHODS: We asked 24,379 consecutive patients aged ≥18years who presented at the psychiatric departments in eight hospitals in 2013 whether they had consumed alcoholic beverages in the previous month. Of the 2964 (12.2%) patients who answered yes and were then screened with the Alcohol Use Disorders Identification Test (AUDIT), 1304 (5...
March 2017: General Hospital Psychiatry
https://www.readbyqxmd.com/read/28251817/wound-management-of-ulcerated-haemangioma-of-infancy%C3%A2-%C3%A2-an-audit
#7
Zerina Lokmic, Taya Grainger, Nadeeja V Atapattu, Roderic J Phillips, Anthony J Penington
Haemangioma of infancy, a benign tumour of blood vessels, is the most common tumour of infancy. Ulceration, the most common complication, presents a unique wound care challenge. A retrospective audit of medical records of children with haemangioma of infancy who presented to the Royal Children's Hospital, Melbourne, Australia, between January 2000 and December 2014 was undertaken with an aim to examine wound management of ulcerated haemangioma of infancy. In total, 535 hospital medical records were identified as suitable, of which 352 were randomly selected and audited, of which 84 patients had ulcerated haemangioma of infancy, and 62 were subject to wound management...
March 1, 2017: International Wound Journal
https://www.readbyqxmd.com/read/28251670/retrospective-audit-of-antimicrobial-prescribing-practices-for-acute-exacerbations-of-chronic-obstructive-pulmonary-diseases-in-a-large-regional-hospital
#8
D J Brownridge, S T R Zaidi
WHAT IS KNOWN AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity and mortality, and frequent exacerbations are associated with an increased risk of death, deterioration in lung function and reduced quality of life. Current Australian guidelines developed by the Lung Foundation of Australia (the COPD-X Plan) recommends the use of a short course of corticosteroids and oral antibiotics (amoxycillin or doxycycline) as part of the treatment of an AECOPD; however, it was noted that clinical practice at the study hospital had deviated from these guidelines...
March 1, 2017: Journal of Clinical Pharmacy and Therapeutics
https://www.readbyqxmd.com/read/28244494/do-primary-care-provider-strategies-improve-patient-participation-in-colorectal-cancer-screening
#9
Nancy N Baxter, Rinku Sutradhar, Qing Li, Corinne Daly, Gladys N Honein-AbouHaidar, Devon P Richardson, Lisa Del Giudice, Jill Tinmouth, Lawrence Paszat, Linda Rabeneck
OBJECTIVES: Screening rates for colorectal cancer (CRC) remain suboptimal. The impact of provider strategies to enhance screening participation in the population is uncertain. The objective of this study was to determine the effect of provider strategies to increase screening in a single-payer system. METHODS: A population-based survey was conducted in primary care providers (PCPs) linked to patients using administrative data in Ontario, Canada. Patients were due for CRC screening from April 2012 to March 2013...
February 28, 2017: American Journal of Gastroenterology
https://www.readbyqxmd.com/read/28241379/necrotising-fasciitis-as-a-complication-of-odontogenic-infection-a-review-of-management-and-case-series
#10
K Bayetto, A Cheng, P Sambrook
OBJECTIVE: To establish the incidence of head and neck necrotising fasciitis (NF) in the Adelaide Oral and Maxillofacial Surgery Unit. To review the current literature regarding the management of head and neck NF. To determine the evidence for the role of hyperbaric oxygen therapy in the management of NF. METHOD: A retrospective audit of all patients admitted to the Royal Adelaide Hospital Oral and Maxillofacial Surgery Unit 2006-2015 with severe odontogenic infections was carried out...
February 27, 2017: Australian Dental Journal
https://www.readbyqxmd.com/read/28240996/impact-of-the-opioid-safety-initiative-on-opioid-related-prescribing-in-veterans
#11
Lewei A Lin, Amy S B Bohnert, Robert D Kerns, Michael A Clay, Dara Ganoczy, Mark A Ilgen
The Veterans Health Administration (VHA) designed the Opioid Safety Initiative (OSI) to help decrease opioid prescribing practices associated with adverse outcomes. Key components included disseminating a dashboard tool that aggregates electronic medical record data to audit real-time opioid-related prescribing and identifying a clinical leader at each facility to implement the tool and promote safer prescribing. This study examines changes associated with OSI implementation in October 2013 among all adult VHA patients who filled outpatient opioid prescriptions...
January 4, 2017: Pain
https://www.readbyqxmd.com/read/28235461/how-well-are-pulses-measured-practice-based-evidence-from-an-observational-study-of-acutely-ill-medical-patients-during-their-hospital-admission
#12
Martin Otyek Opio, John Kellett
INTRODUCTION: although taking a radial pulse is considered to be an essential clinical skill there have been few reports on how well it is measured in clinical practice, and how its accuracy and precision are influenced by rate, rhythm and blood pressure. METHODS: this study is a retrospective quality audit carried out as part of a larger ongoing prospective observational trial. The radial pulse rates recorded by two research nurses were compared with the ECG heart rates measured on acutely ill medical patients during their admission to a resource poor hospital in sub-Saharan Africa...
February 21, 2017: American Journal of Medicine
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
#13
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
#14
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
#15
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
#16
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
#17
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
#18
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
#19
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
#20
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
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