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Medical record audit

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https://www.readbyqxmd.com/read/29324564/falls-assessment-and-interventions-among-older-patients-in-two-medical-and-one-surgical-hospital-wards-in-spain-a-best-practice-implementation-project
#1
Laura Albornos-Muñoz, Esther Melián-Correa, Amanda Acosta-Arrocha, Carmen Gallo-Blanco, Felicidad Béjar-Bacas, Emma Alonso-Poncelas, Montserrat Serra-Estrada, Esther González-María, María Teresa Moreno-Casbas
OBJECTIVE: The current project aimed to improve fall prevention and management through clinical audits and the implementation of a quality-improvement cycle at the local level. INTRODUCTION: Falls are one of the most common adverse events reported in hospitals; evidence-based fall prevention interventions aim to reduce the number of people who fall. METHODS: A one-year clinical audit was conducted using a pre-post implementation audit method, namely the Joanna Briggs Institute's (JBI) Practical Application of Clinical Evidence System and the getting research into practice audit and feedback tool...
January 2018: JBI Database of Systematic Reviews and Implementation Reports
https://www.readbyqxmd.com/read/29302880/a-framework-for-tracking-former-patients-in-the-electronic-health-record-using-an-educational-registry
#2
Gregory E Brisson, Cynthia Barnard, Patrick D Tyler, David M Liebovitz, Kathy Johnson Neely
One challenge of contemporary medical education is that shorter lengths of stay and time-limited clerkships often interrupt a student's relationship with a patient before a diagnosis is made or treatment is completed, limiting the learning experience. Medical students sometimes use electronic health records (EHRs) to overcome these limitations. EHRs provide access to patients' future medical records, enabling students to track former patients across care venues to audit their diagnostic impressions and observe outcomes...
January 4, 2018: Journal of General Internal Medicine
https://www.readbyqxmd.com/read/29299001/development-of-a-documentation-rubric-and-assessment-of-pharmacists-competency-for-documentation-in-the-patient-health-record
#3
Brittany Baranski, Jennifer Bolt, Lori Albers, Rabiah Siddiqui, Ali Bell, William Semchuk
Background: Documentation of information in the health record by pharmacists is vital to patient care. Failure to document, or failure to document appropriately, may have negative effects on patients. Objectives: The primary objective was to determine pharmacists' competency in 18 elements of chart note documentation at 2 tertiary care centres and 1 rehabilitation centre. The secondary objectives were to quantify the number of episodes of documentation by pharmacists, to characterize the clinical activities associated with this documentation, and to determine whether there were differences in level of competency according to years of hospital experience, additional clinical training, and note type...
November 2017: Canadian Journal of Hospital Pharmacy
https://www.readbyqxmd.com/read/29298778/acanthamoeba-keratitis-in-194-patients-risk-factors-for-bad-outcomes-and-severe-inflammatory-complications
#4
Nicole Carnt, Dana Robaei, Darwin C Minassian, John K G Dart
BACKGROUND/AIMS: To determine demographic and clinical features of patients with Acanthamoeba keratitis (AK) that are independent risk factors both for bad outcomes and for severe inflammatory complications (SIC). METHODS: A retrospective audit of medical records of AK cases at Moorfields Eye Hospital from July 2000 to April 2012, including 12 earlier surgical cases. Cases with a bad outcome were defined as those having one or more of the following: corneal perforation, keratoplasty, other surgery (except biopsy), duration of antiamoebic therapy (AAT) ≥10...
January 3, 2018: British Journal of Ophthalmology
https://www.readbyqxmd.com/read/29297865/using-health-care-audit-to-improve-quality-of-clinical-records-the-preliminary-experience-of-an-italian-cancer-institute
#5
Chiara Cadeddu, Maria Lucia Specchia, Pasquale Cacciatore, Raffaele Marchini, Walter Ricciardi, Costanza Cavuto
INTRODUCTION: Audit and feedback are recognized as part of a strategy for improving performance and supporting quality and safety in European health care systems. These considerations led the Clinical Management Staff of the "Regina Elena" Italian Cancer Institute to start a project of self-assessment of the quality of clinical records and organizational appropriateness through a retrospective review. MATERIALS AND METHODS: The evaluation about appropriateness and congruity concerned both clinical records of 2013 and of 2015...
October 2017: Annali Dell'Istituto Superiore di Sanità
https://www.readbyqxmd.com/read/29297401/improving-data-quality-across-3-sub-saharan-african-countries-using-the-consolidated-framework-for-implementation-research-cfir-results-from-the-african-health-initiative
#6
Sarah Gimbel, Moses Mwanza, Marie Paul Nisingizwe, Cathy Michel, Lisa Hirschhorn
BACKGROUND: High-quality data are critical to inform, monitor and manage health programs. Over the seven-year African Health Initiative of the Doris Duke Charitable Foundation, three of the five Population Health Implementation and Training (PHIT) partnership projects in Mozambique, Rwanda, and Zambia introduced strategies to improve the quality and evaluation of routinely-collected data at the primary health care level, and stimulate its use in evidence-based decision-making. Using the Consolidated Framework for Implementation Research (CFIR) as a guide, this paper: 1) describes and categorizes data quality assessment and improvement activities of the projects, and 2) identifies core intervention components and implementation strategy adaptations introduced to improve data quality in each setting...
December 21, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/29297319/data-driven-quality-improvement-in-low-and-middle-income-country-health-systems-lessons-from-seven-years-of-implementation-experience-across-mozambique-rwanda-and-zambia
#7
Bradley H Wagenaar, Lisa R Hirschhorn, Catherine Henley, Artur Gremu, Ntazana Sindano, Roma Chilengi
BACKGROUND: Well-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Over the last 7 years, the Doris Duke Charitable Foundation's African Health Initiative funded health systems strengthening projects at the facility, district, and/or provincial level to improve population health. Increasing data-driven decision making was a common strategy in Mozambique, Rwanda and Zambia...
December 21, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/29297206/no-jab-no-record-catch-up-vaccination-of-children-in-immigration-detention
#8
Karen M Kiang, Sonja Elia, Georgia A Paxton
International Health and Medical Services (IHMS) are contracted to provide health services, including catch-up vaccination, for individuals in immigration detention. Our audit of catch-up vaccination in asylum seeker children who spent time in held detention demonstrates inadequate and suboptimal vaccine delivery in this setting, and no evidence that IHMS recorded vaccines on the Australian Childhood Immunisation Register at the time. We also found substantial shortfalls in vaccination for these children after they were released from detention...
January 3, 2018: Journal of Paediatrics and Child Health
https://www.readbyqxmd.com/read/29283918/clinical-utility-of-intraoperative-motor-evoked-potential-monitoring-to-prevent-postoperative-spinal-cord-injury-in-thoracic-and-thoracoabdominal-aneurysm-repair-an-audit-of-the-japanese-association-of-spinal-cord-protection-in-aortic-surgery-database
#9
Kenji Yoshitani, Kenichi Masui, Masahiko Kawaguchi, Mikito Kawamata, Manabu Kakinohana, Shinya Kato, Kyoko Hasuwa, Michiaki Yamakage, Yusuke Yoshikawa, Kimitoshi Nishiwaki, Tadashi Aoyama, Yoshimi Inagaki, Kazumasa Yamasaki, Mishiya Matsumoto, Kazuyoshi Ishida, Atsuo Yamashita, Katsuhiro Seo, Shinichi Kakumoto, Hironobu Hayashi, Yuu Tanaka, Satoshi Tanaka, Takashi Ishida, Hiroyuki Uchino, Takayasu Kakinuma, Yoshitsugu Yamada, Yoshiteru Mori, Shunsuke Izumi, Kunihiro Nishimura, Michikazu Nakai, Yoshihiko Ohnishi
BACKGROUND: Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits...
December 26, 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/29283293/resource-planning-in-glaucoma-a-tool-to-evaluate-glaucoma-service-capacity
#10
Ruchika Batra, Hannah E Sharma, Ibrahim Elaraoud, Shabbir Mohamed
BACKGROUND: The National Patient Safety Agency (2009) publication advising timely follow-up of patients with established glaucoma followed several reported instances of visual loss due to postponed appointments and patients lost to follow-up. The Royal College of Ophthalmologists Quality Standards Development Group stated that all hospital appointments should occur within 15% of the intended follow-up period. AIM: To determine whether: 1. Glaucoma follow-up appointments at a teaching hospital occur within the requested time 2...
December 28, 2017: Seminars in Ophthalmology
https://www.readbyqxmd.com/read/29277487/training-program-for-pain-assessment-in-the-newborn
#11
E Carpentier, F Moreau, S Soriot-Thomas, P Tourneux
AIM: Pain management is correlated with pain assessment in the newborn infant. The aim of this study was to assess the impact of a 2-week training program composed of short (20min), repeated training sessions conducted in the unit. METHODS: Pain assessment was studied by means of audits. Each audit included data recorded from the newborn infant's medical charts on the day the infant was admitted to the unit and 3 days before the audit. An audit was performed before the training program and then repeated every month for 12 months...
January 2018: Archives de Pédiatrie: Organe Officiel de la Sociéte Française de Pédiatrie
https://www.readbyqxmd.com/read/29275460/implementation-of-a-regional-perinatal-data-repository-from-clinical-and-billing-records
#12
Eric S Hall, James M Greenberg, Louis J Muglia, Parth Divekar, Janet Zahner, Jay Gholap, Matt Leonard, Keith Marsolo
Objectives To describe the implementation of the first phase of a regional perinatal data repository and to provide a roadmap for others to navigate technical, privacy, and data governance concerns in implementing similar resources. Methods Our implementation integrated regional physician billing records with maternal and infant electronic health records from an academic delivery hospital. These records, representing births during 2013-2015, constituted a data core supporting linkage to additional ancillary data sets...
December 23, 2017: Maternal and Child Health Journal
https://www.readbyqxmd.com/read/29273212/factors-contributing-to-variation-in-the-use-of-multimodality-treatment-in-patients-with-gastric-cancer-a-dutch-population-based-study
#13
N Beck, L A D Busweiler, M G Schouwenburg, M Fiocco, A Cats, F E M Voncken, B P L Wijnhoven, M I van Berge Henegouwen, M W J M Wouters, J W van Sandick
BACKGROUND: Substantial variation in the use of (neo) adjuvant treatment in patients with gastric cancer exists. The aim of this study was to identify underlying (organizational and process) factors associated with the use of perioperative therapy. PATIENTS AND METHODS: Patients with resectable gastric cancer who underwent surgery between 2012 and 2014 were selected from the Dutch Upper gastrointestinal Cancer Audit (DUCA). The proportion of perioperatively treated patients was defined per hospital...
December 13, 2017: European Journal of Surgical Oncology
https://www.readbyqxmd.com/read/29260253/rates-of-glycaemic-deterioration-in-a-real-world-population-with-type-2-diabetes
#14
Louise A Donnelly, Kaixin Zhou, Alex S F Doney, Chris Jennison, Paul W Franks, Ewan R Pearson
AIMS/HYPOTHESIS: There is considerable variability in how diabetes progresses after diagnosis. Progression modelling has largely focused on 'time to failure' methods, yet determining a 'coefficient of failure' has many advantages. We derived a rate of glycaemic deterioration in type 2 diabetes, using a large real-world cohort, and aimed to investigate the clinical, biochemical, pharmacological and immunological variables associated with fast and slow rates of glycaemic deterioration. METHODS: An observational cohort study was performed using the electronic medical records from participants in the Genetics of Diabetes Audit and Research in Tayside Study (GoDARTS)...
December 19, 2017: Diabetologia
https://www.readbyqxmd.com/read/29242846/high-prevalence-of-dyslipidemia-among-primary-care-patients-with-hypertension-and-diabetes-in-jamaica
#15
Michelle A Harris, Trevor S Ferguson, Michael S Boyne, J Peter Figueroa
Introduction: The aim of the study was to determine the prevalence of dyslipidemia among primary care patients with hypertension and diabetes in Jamaica and the proportion of patients who achieve recommended targets. Material and methods: An audit of 500 dockets of adult patients with chronic disease attending public primary care clinics in Jamaica was conducted between October and December 2013. Data were collected on patient characteristics including medical history, medications, anthropometry, and lipid profiles (since January 1, 2011)...
2017: Archives of Medical Sciences. Atherosclerotic Diseases
https://www.readbyqxmd.com/read/29240741/a-retrospective-audit-of-the-characteristics-and-treatment-outcomes-in-patients-with-diabetes-related-charcot-neuropathic-osteoarthropathy
#16
Joanne Dixon, Joshua Coulter, Michele Garrett, Rick Cutfield
AIMS: To review the characteristics, management and outcomes one year after diagnosis in patients with diabetes related charcot neuropathic osteoarthropathy (CN) treated at the Diabetes Podiatry service, Waitemata District Health Board (WDHB) between 2000-2014. METHODS: Patients with diabetes and recorded diagnosis of CN were identified from the podiatry service records. Clinical details were retrospectively obtained from WDHB databases and patient medical records...
December 15, 2017: New Zealand Medical Journal
https://www.readbyqxmd.com/read/29232502/do-treatment-patterns-alter-beliefs-cancer-patients-hold-regarding-oral-oncolytic-agents
#17
Alla Sikorskii, Charles W Given, Barbara A Given, Eric Vachon, Victoria Marshall, John C Krauss, Asish Banik, Atreyee Majumder
OBJECTIVE: Cancer patients, particularly those prescribed oral oncolytic medications, face treatment side effects, and temporary and permanent stoppages of treatment. This research examines how events during treatment affect patients' beliefs regarding oral oncolytic medications. METHODS: 272 cancer patients initiating one of 28 oral oncolytic agents were followed for 12 weeks. Assessments of Beliefs About Medications Questionnaire (BMQ), symptoms, physical function, and depression measures were performed during telephone interviews at intake (medication start) and 4, 8, and 12 weeks...
December 12, 2017: Psycho-oncology
https://www.readbyqxmd.com/read/29232365/monitoring-compliance-with-standards-of-care-for-chronic-diseases-using-healthcare-administrative-databases-in-italy-strengths-and-limitations
#18
Rosa Gini, Martijn J Schuemie, Alessandro Pasqua, Emanuele Carlini, Francesco Profili, Iacopo Cricelli, Patrizio Dazzi, Valentina Barletta, Paolo Francesconi, Francesco Lapi, Andrea Donatini, Giulia Dal Co, Modesta Visca, Mariadonata Bellentani, Miriam Sturkenboom, Niek Klazinga
BACKGROUND: A recent comprehensive report on healthcare quality in Italy published by the Organization of Economic Co-operation and Development (OECD) recommended that regular monitoring of quality of primary care by means of compliance with standards of care for chronic diseases is performed. A previous ecological study demonstrated that compliance with standards of care could be reliably estimated on regional level using administrative databases. This study compares estimates based on administrative data with estimates based on GP records for the same persons, to understand whether ecological fallacy played a role in the results of the previous study...
2017: PloS One
https://www.readbyqxmd.com/read/29227054/auditing-surgical-service-provision-at-a-south-african-tertiary-institution-implications-for-the-development-of-district-services
#19
G L Laing, D L Skinner, J L Bruce, C Aldous, V Govindasamy, S R Thomson, D L Clarke
BACKGROUND: The optimal management of resources within South African state hospitals has been hampered by a paucity of data due to a lack of robust auditing information systems. This study reviews the use of a Hybrid Electronic Medical Record (HEMR) system to capture and aggregate data pertaining to the inpatient service demands on a South African tertiary surgical service. This dataset was used to analyse the appropriateness of tertiary surgical resource utilisation. METHOD: The HEMR system was implemented at Greys Hospital, in the city of Pietermaritzburg, Kwa-Zulu Natal, South Africa on 1 January 2013...
November 2017: South African Journal of Surgery. Suid-Afrikaanse Tydskrif Vir Chirurgie
https://www.readbyqxmd.com/read/29216748/quality-of-care-for-patients-with-diabetes-and-mulitmorbidity-registered-at-nurse-practitioner-led-clinics
#20
Roberta Heale, Elizabeth Wenghofer, Susan James, Marie-Luce Garceau
Background Nurse Practitioner-Led Clinics are a new model of primary healthcare in Ontario. Nurse Practitioner-Led Clinics are distinctive in that nurse practitioners are the primary care providers working with an interprofessional team. There have been no evaluations of the quality of care within the Nurse Practitioner-Led Clinic model. Purpose Evaluation of the Nurse Practitioner-Led Clinic model, specifically for complex clinical presentations, will provide insights that may be used to inform improvements to the delivery of care in the Nurse Practitioner-Led Clinics...
January 1, 2017: Canadian Journal of Nursing Research, Revue Canadienne de Recherche en Sciences Infirmières
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