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Medical record audit

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https://www.readbyqxmd.com/read/28107309/-delay-to-operating-room-fails-to-identify-adverse-outcomes-at-a-level-i-trauma-center
#1
Paul R Lewis, Jayraan Badiee, Michael J Sise, Richard Y Calvo, Jason B Brill, James D Wallace, Steven R Shackford, Casey E Dunne, Vishal Bansal, C Beth Sise
BACKGROUND: The American College of Surgeons Committee on Trauma devised process audit filters to identify opportunities for improvement (OFI), prevent adverse outcomes, and improve quality. Delay to the operating room for primary trauma laparotomy is a process audit filter that has not been definitively associated with improved outcomes. We sought to evaluate the effectiveness of delay to the operating room of greater than 2 hours (DOR) to independently identify an adverse outcome or an OFI at our Level I trauma center...
February 2017: Journal of Trauma and Acute Care Surgery
https://www.readbyqxmd.com/read/28104042/electronic-health-records-and-online-medical-records-an-asset-or-a-liability-under-current-conditions
#2
Judith Allen-Graham, Lauren Mitchell, Natalie Heriot, Roksana Armani, David Langton, Michele Levinson, Alan Young, Julian A Smith, Tom Kotsimbos, John W Wilson
Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information.Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital's current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary...
January 20, 2017: Australian Health Review: a Publication of the Australian Hospital Association
https://www.readbyqxmd.com/read/28096916/an-audit-of-referral-and-treatment-patterns-of-high-risk-prostate-cancer-patients-in-alberta
#3
Majed Alghamdi, Amandeep Taggar, Derek Tilley, Marc Kerba, Xanthoula Kostaras, Geoffrey Gotto, Michael Sia
INTRODUCTION: We aimed to determine the impact of clinical practice guidelines (CPG) on rates of radiation oncologist (RO) referral, androgen-deprivation therapy (ADT), radiation therapy (RT), and radical prostatectomy (RP) in patients with high-risk prostate cancer (HR-PCa). METHODS: All men >18 years, diagnosed with PCa in 2005 and 2012 were identified from the Alberta Cancer Registry. Patient age, aggregated clinical risk group (ACRG) score, Gleason score (GS), pre-treatment prostate-specific antigen (PSA), RO referral, and treatment received were extracted from electronic medical records...
November 2016: Canadian Urological Association Journal, Journal de L'Association des Urologues du Canada
https://www.readbyqxmd.com/read/28093900/who-is-responsible-for-metabolic-screening-for-mental-health-clients-taking-antipsychotic-medications
#4
Tamara Ward, Dianne Wynaden, Karen Heslop
Metabolic syndrome is common in mental health consumer populations, and is linked to cardiovascular disease, stroke and diabetes. Metabolic screening is a way of recognising consumers who are at risk of developing metabolic syndrome but internationally screening rates remain low. A retrospective audit was completed at one Australian public mental health service on the case files of 100 randomly selected consumers to determine nurses level of compliance with metabolic screening policies over a 12 month period...
January 17, 2017: International Journal of Mental Health Nursing
https://www.readbyqxmd.com/read/28086813/information-exchange-networks-of-health-care-providers-and-evidence-based-cardiovascular-risk-management-an-observational-study
#5
Naomi Heijmans, Jan van Lieshout, Michel Wensing
BACKGROUND: Although a wide range of preventive and clinical interventions has targeted cardiovascular risk management (CVRM), outcomes remain suboptimal. Therefore, the question is what additional determinants of CVRM and outcomes can be identified and addressed to optimize CVRM. In this study, we aimed to identify new perspectives for improving healthcare delivery and explored associations between information exchange networks of health care providers and evidence-based CVRM. METHODS: This observational study was performed parallel to a randomized clinical trial which aimed to improve professional performance of practice nurses in the Netherlands...
January 13, 2017: Implementation Science: IS
https://www.readbyqxmd.com/read/28074520/assessing-the-accuracy-of-opioid-overdose-and-poisoning-codes-in-diagnostic-information-from-electronic-health-records-claims-data-and-death-records
#6
Carla A Green, Nancy A Perrin, Shannon L Janoff, Cynthia I Campbell, Howard D Chilcoat, Paul M Coplan
PURPOSE: The purpose of this study is to assess positive predictive value (PPV), relative to medical chart review, of International Classification of Diseases (ICD)-9/10 diagnostic codes for identifying opioid overdoses and poisonings. METHODS: Data were obtained from Kaiser Permanente Northwest and Northern California. Diagnostic data from electronic health records, submitted claims, and state death records from Oregon, Washington, and California were linked. Individual opioid-related poisoning codes (e...
January 10, 2017: Pharmacoepidemiology and Drug Safety
https://www.readbyqxmd.com/read/28073650/the-utilisation-of-one-district-hospital-emergency-department-by-people-with-parkinson-s-disease
#7
Marion Harris, Margaret Fry
BACKGROUND: Parkinson's disease (PD) is the second most common neurodegenerative disorder in Australia and the economic burden is more than $8.3 billion a year and predicted to escalate. However, little is known of the trends and characteristics of people with Parkinson's disease presenting to emergency departments (ED). METHOD: The study design was a 12 month retrospective medical record audit. The study was conducted in one metropolitan 300 bed district hospital in an outer suburb of Sydney...
January 7, 2017: Australasian Emergency Nursing Journal: AENJ
https://www.readbyqxmd.com/read/28071865/the-impact-of-evidence-based-sepsis-guidelines-on-emergency-department-clinical-practice-a-pre-post-medical-record-audit
#8
Bernadine Romero, Margaret Fry, Michael Roche
AIMS AND OBJECTIVES: The aim of this study was to explore the number of patients presenting with sepsis before and after guideline implementation; the impact of sepsis guidelines on triage assessment, Emergency Department management and time to antibiotics. BACKGROUND: Sepsis remains one of the leading causes of mortality and morbidity within hospitals. Globally, strategies have been implemented to reduce morbidity and mortality rates, which rely on the early recognition and management of sepsis...
January 10, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/28065330/impact-of-personalized-report-cards-on-nurses-managing-central-lines
#9
Theresa Morrison, Jacqueline Raffaele, Laura Brennaman
BACKGROUND: The purpose of this quality improvement project was to determine the effect of providing feedback to managers and bedside nurses on the nurses' central line-associated bloodstream infection (CLABSI) contributing factors, found on visual and documentation audits. METHODS: This nonexperimental, quality improvement project was conducted in a 715-bed, 2-campus acute care community hospital health care system in Southwest Florida. The intervention consisted of providing confidential feedback on central line audits deviations, through the systematic delivery of unit case reports and personalized nurse report cards...
January 1, 2017: American Journal of Infection Control
https://www.readbyqxmd.com/read/28059690/accuracy-of-screening-tools-for-pap-smears-in-general-practice
#10
Catherine Harding, Alexa Seal, Louis Pilotto, Ken Mackey, Geraldine Duncan, Ronald Huynh, Robert McWilliam, Stephanie Blake
BACKGROUND: Data extraction tools (DETs) are increasingly being used for research and audit of general practice, despite their limitations.Objective This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit. METHOD: A widely available DET was used to establish the rate of Pap smears in a large multi-general practice (multi-GP) in regional New South Wales followed by a manual audit of patient files...
September 13, 2016: Journal of Innovation in Health Informatics
https://www.readbyqxmd.com/read/28057873/attainment-of-guideline-targets-in-eurodopps-haemodialysis-patients-are-differences-related-to-a-country-s-healthcare-expenditure-and-nephrologist-workforce
#11
Sophie Liabeuf, Karlijn J Van Stralen, Fergus Caskey, Francesca Tentori, Ronald L Pisoni, Ayesha Sajjad, Kitty J Jager, Ziad A Massy
BACKGROUND: In the field of chronic kidney disease, global clinical practice guidelines have been developed and implemented with a view to improving patient care and outcomes. The attainment of international and European guideline targets for haemodialysis patients in European countries has not been audited recently. Hence, we sought to establish whether the attainment of the targets set out in guidelines and inappropriate care are similar across European countries and whether inter-country differences are related to disparities in national healthcare expenditures (as a percentage of gross domestic product) and/or the nephrologist workforce per capita...
January 5, 2017: Nephrology, Dialysis, Transplantation
https://www.readbyqxmd.com/read/28057660/protocol-for-intraoperative-assessment-of-the-human-cerebrovascular-glycocalyx
#12
R H L Haeren, H Vink, J Staals, M A M J van Zandvoort, J Dings, J J van Overbeeke, G Hoogland, K Rijkers, O E M G Schijns
INTRODUCTION: Adequate functioning of the blood-brain barrier (BBB) is important for brain homoeostasis and normal neuronal function. Disruption of the BBB has been described in several neurological diseases. Recent reports suggest that an increased permeability of the BBB also contributes to increased seizure susceptibility in patients with epilepsy. The endothelial glycocalyx is coating the luminal side of the endothelium and can be considered as the first barrier of the BBB. We hypothesise that an altered glycocalyx thickness plays a role in the aetiology of temporal lobe epilepsy (TLE), the most common type of epilepsy...
January 5, 2017: BMJ Open
https://www.readbyqxmd.com/read/28043767/bleeding-after-circumcision-is-more-likely-in-children-with-lichen-sclerosus-balanitis-xerotica-obliterans
#13
P Somov, B K Y Chan, C Wilde, H Corbett
INTRODUCTION: Over 27,000 circumcisions were performed in England in 2012-13. The complication rate is generally perceived to be low, although published figures vary widely. Balanitis xerotica obliterans, more correctly termed Lichen Sclerosus et atrophicus (LS), is one of the commonest indications for medical circumcision. To test the hypothesis that children undergoing circumcision for LS have a higher rate of postoperative bleeding than those undergoing the procedure for other reasons, we retrospectively reviewed records for patients undergoing circumcision...
December 9, 2016: Journal of Pediatric Urology
https://www.readbyqxmd.com/read/28027668/social-determinants-of-health-and-retention-in-hiv-care-in-a-clinical-cohort-in-ontario-canada
#14
Beth Rachlis, Ann N Burchell, Sandra Gardner, Lucia Light, Janet Raboud, Tony Antoniou, Jean Bacon, Anita Benoit, Curtis Cooper, Claire Kendall, Mona Loutfy, Wendy Wobeser, Frank McGee, Anita Rachlis, Sean B Rourke
: Continuous HIV care supports antiretroviral therapy initiation and adherence, and prolongs survival. We investigated the association of social determinants of health (SDH) and subsequent retention in HIV care in a clinical cohort in Ontario, Canada. The Ontario HIV Treatment Network Cohort Study is a multi-site cohort of patients at 10 HIV clinics. Data were collected from medical charts, interviews, and via record linkage with the provincial public health laboratory for viral load tests...
December 27, 2016: AIDS Care
https://www.readbyqxmd.com/read/28027164/meeting-the-needs-for-radiation-protection-diagnostic-imaging
#15
Donald P Frush
Radiation and potential risk during medical imaging is one of the foremost issues for the imaging community. Because of this, there are growing demands for accountability, including appropriate use of ionizing radiation in diagnostic and image-guided procedures. Factors contributing to this include increasing use of medical imaging; increased scrutiny (from awareness to alarm) by patients/caregivers and the public over radiation risk; and mounting calls for accountability from regulatory, accrediting, healthcare coverage (e...
February 2017: Health Physics
https://www.readbyqxmd.com/read/28003897/use-of-prescription-drugs-and-investigations-by-doctors-in-primary-care-settings-in-oman-and-the-uk
#16
Robin Davidson
OBJECTIVES: This audit aimed to investigate the use of prescription drugs and investigations by trainee doctors in primary care settings in Oman and the UK. METHODS: This audit took place between February and April 2015. The medical records of consecutive patients seen by five family medicine trainee doctors at a primary care setting in Oman were retrospectively reviewed. These data were compared to those gathered from two trainees at a general practice clinic in the UK as well as an experienced general practitioner (GP) who had practiced in both countries...
November 2016: Sultan Qaboos University Medical Journal
https://www.readbyqxmd.com/read/28003757/results-of-a-venous-thromboembolism-prophylaxis-program-for-hospitalized-patients
#17
Luiz Francisco Cardoso, Daniella Vianna C Krokoscz, Edison Ferreira de Paiva, Ilka Spinola Furtado, Jorge Mattar, Marcia Martiniano de Souza E Sá, Antonio Carlos Onofre de Lira
INTRODUCTION: Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. However, existing prophylaxis guidelines are rarely followed. OBJECTIVE: The aim of the study was to present and discuss implementation strategies and the results of a VTE prophylaxis program for medical and surgical patients admitted to a large general hospital. PATIENTS AND METHODS: This prospective observational study was conducted to describe the strategy used to implement a VTE prophylaxis program in hospitalized medical and surgical patients and to analyze the results in terms of the risk assessment rate within the first 24 hours after admission, adequacy of the prophylaxis prescription, and prevalence of VTE in the discharge records before and after program implementation...
2016: Vascular Health and Risk Management
https://www.readbyqxmd.com/read/27993546/post-resuscitation-management-of-cardiac-arrest-patients-in-the-critical-care-environment-a-retrospective-audit-of-compliance-with-evidence-based-guidelines
#18
REVIEW
A Milonas, A Hutchinson, D Charlesworth, A Doric, J Green, J Considine
BACKGROUND: There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. The Australian Resuscitation Council (ARC) recommends protocol driven care to enhance chance of survival following cardiac arrest. Healthcare providers have an obligation to ensure protocol driven post resuscitation care is timely and evidence based. OBJECTIVES: The aim of this study was to examine adherence to best practice guidelines for post resuscitation care in the first 24h from Return of Spontaneous Circulation for patients admitted to the intensive care unit from the emergency department having suffered out of hospital or emergency department cardiac arrest and survived initial resuscitation...
December 16, 2016: Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses
https://www.readbyqxmd.com/read/27981769/documentation-of-consent-for-blood-transfusion
#19
C Hennessy, M Borosak, L Bielby, L J Stevenson, B Glazebrook
In 2012, 110 hospitals reported on consent policy against national guidelines, with 105 (95%) including a statement on blood transfusion. Of the 103 hospitals (1788 transfusion episodes) that participated in the consent practice component, 89 specified the method of consent used; 46 (52%) had a specific transfusion consent form and achieved compliance of 90% compared to 43-69% for most other methods. The consent audit shows that a specific blood consent form achieved a high rate of medical record documentation compliance...
December 2016: Internal Medicine Journal
https://www.readbyqxmd.com/read/27964898/sorafenib-for-the-treatment-of-advanced-hepatocellular-cancer-a-uk-audit
#20
J King, D H Palmer, P Johnson, P Ross, R A Hubner, K Sumpter, S Darby, C Braconi, C Iwuji, D Swinson, P Collins, K Patel, J Nobes, I Muazzam, C Blesing, A Kirkwood, S Nash, T Meyer
AIMS: Sorafenib is the current standard treatment for advanced hepatocellular carcinoma. We carried out a national audit of UK patients treated with sorafenib as standard-of-care and those treated with systemic therapy in first-line trials. MATERIALS AND METHODS: Sorafenib-treated and trial-treated patients were identified via the Cancer Drugs Fund and local databases. Data were collected retrospectively from medical records according to a standard case report form...
December 10, 2016: Clinical Oncology: a Journal of the Royal College of Radiologists
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