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Clinical Documentation (clinical + documentation)
Selected AbstractsA variant TGFBI corneal dystrophy from G623D mutation with an unusual amyloidogenic phenotypeACTA OPHTHALMOLOGICA, Issue 2009HT AGOSTINI Purpose To present a unique corneal dystrophy never before described in a German family carrying the Gly623Asp mutation of the TGFBI gene with late clinical onset. Methods Clinical documentation and isolation of genomic DNA from peripheral blood leucocytes were obtained from each family member examined. Exons 3, 4, 5, and 11 to 14 of the TGFBI gene were sequenced. 5 corneal buttons of 3 affected siblings were excised at the time of penetrating keratoplasty. Light and electron microscopic examination were performed including immunohistochemistry with antibodies against Keratoepithelin (KE) 2 and 15. Results Specimens showed changes in Bowman's layer and the adjacent stroma. Congo red-positive amyloid deposits were found within the epithelium in one cornea, in Bowman's layer and in the anterior stroma of all specimens, also showing KE2- but not KE15-immunostaining. EM revealed deposits located in the anterior stroma and Bowman's layer and the basal area of some epithelial cells. These areas were strongly Alcian blue-positive but negative in the Masson-Trichrom-stain. Only affected patients had a heterozygous missense mutation in exon 14 of the TGFBI gene (G->A transition at nucleotide 1915) with the change Gly623Asp in the keratoepithelin protein. Conclusion In contrast to the patient carrying the Gly623Asp mutation of the TGFBI gene described by Afshari et al., our cases presented with Salzmann nodular degeneration like clinical features with KE2 positive amyloid. The reason for this now "meeting the expectation histological phenotype" is unclear. The histological findings emphasize that this is a unique corneal dystrophy which shares no clinical characteristics with Reis-Bücklers dystrophy and should be treated as a distinct entity. [source] Implementation of Standardized Nomenclature in the Electronic Medical RecordINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 4 2009Joan Klehr RNC MPH PURPOSE., To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. DATA SOURCES., Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. CONCLUSIONS AND IMPLICATIONS., Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation. [source] An Internet-Based Survey of Icelandic Nurses on Their Use of and Attitudes Toward NANDA, NIC, and NOCINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003Gyda Bjornsdottir PURPOSE To gain understanding of how Icelandic nurses can be supported during a mandated change to the use of NANDA and NIC in clinical documentation practices. METHODS All members of the Icelandic Nurses Association of working age were invited to participate in an Internet-based survey. Each nurse was assigned a unique password mailed to his/her home along with information on how to access the survey Web site. Each nurse could submit answers only once. On submission, data were automatically coded and saved in a database under encrypted numerical identifiers. FINDINGS A total of 463 nurses (18% response rate) participated by submitting answers. The sample was representative of the population in terms of demographic characteristics. Information resources most valued when planning nursing care included text-based progress notes (77%), nursing care plans (52%), doctor's orders (49%), verbal information (48%), and documented nursing diagnoses (37%). Of the participants, 58% said NANDA was used in their workplace; 28% said no standardized nursing documentation was used; 19% reported using NIC always or sometimes when documenting nursing interventions; and 20% never used NIC. NOC use was reported only by researchers. Of the sample, 86% reported that it is important or necessary for nurses to standardize documentation practices; 30% found NANDA useful in education; 56% found it useful for clinical work; 17% for research; and 7% found it not useful at all. Nine percent believed that NANDA diagnoses were not descriptive enough of patients' problems, and 23% found their wording problematic. No statistically significant differences were found between reported use of or attitudes toward NANDA and NIC when comparing nurses who use electronic patient record systems that support NANDA and NIC documentation and those who use paper documentation only. DISCUSSION The sample may have been somewhat biased toward computer use and classification system use for standardized and computerized documentation. However, results indicate that although Icelandic nurses give free-text progress notes and verbal information a higher priority than nursing diagnoses as an information resource for care planning, they have a positive attitude toward NANDA. NANDA and NIC are still used inconsistently in clinical practice, and 28% of participants claimed not to use any form of standardized documentation. CONCLUSIONS In an effort to standardize clinical documentation among nurses, Icelandic health authorities must follow their documentation mandates with educational and technologic support to facilitate the use of NANDA, NIC, and (after its translation) NOC in nursing documentation practices. Electronic patient record system developers must find ways to further facilitate standardized nursing documentation because currently there seems to be no difference between users and nonusers in terms of how they use NANDA and NIC in their documentation practices. [source] Clinical evaluation tools for dual track adult and gerontology nurse practitioner studentsJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 12 2009Adult Health Nurse Practitioner Program, Director, FAANP Advanced Senior Lecturer, Valerie T. Cotter MSN Abstract Purpose: To describe the development of a dual track offering for the Adult Health and Gerontology Nurse Practitioner (AGNP) Programs at the University of Pennsylvania School of Nursing and share clinical evaluation tools used with nurse practitioner students in this curriculum. Data sources: Selected research and clinical articles. Conclusions: A variety of evaluation approaches are utilized in the AGNP student clinical performance evaluation. These incorporate the extended clinical practicum sequence for the dual track curriculum in addition to each individual program's objectives. Formative and summative evaluations include reflective logs, clinical documentation of patient encounters, preceptor evaluation, and faculty site visits. Self-evaluative skills of the student and quality faculty feedback are two additional integral components that facilitate learning outcomes in the cognitive, psychomotor, and affective learning domains. Implications for practice: The summary of evaluation tools presented here is an example of how the AGNP Programs at the University of Pennsylvania School of Nursing effectively measure student progress in a curriculum model for dual track enrollment. [source] Deep brain stimulation for dystonia: Patient selection and evaluationMOVEMENT DISORDERS, Issue S3 2002Jens Volkmann MD Abstract Deep brain stimulation (DBS) for dystonia still needs to be considered investigational, because there are no controlled studies for this indication, the optimal target point is uncertain, and long-term effects are unknown. The striking improvement of levodopa-induced dyskinesias in Parkinson's disease by deep brain stimulation of the internal pallidum has encouraged the use of this therapy for generalized and severe segmental dystonia in children and adults. Single case and small cohort studies have reported impressive efficacy of pallidal DBS in patients with primary dystonia, especially DYT1 mutation carriers, but results in secondary dystonia are less conclusive. This article discusses the different factors influencing patient selection for surgical treatment and describes standardized methods and the caveats for clinical documentation of treatment results in dystonia. © 2002 Movement Disorder Society [source] 2465: Phenotype/genotype evolution in corneal embryologic malformationsACTA OPHTHALMOLOGICA, Issue 2010KK NISCHAL Purpose To describe the evolution of a clinically useful classification of corneal developmental anomalies which has also allowed more accurate phenotype/genotype correlation. Methods The use of clinical documentation using anterior segment photography, normal ultrasound of the eyeball, and high frequency ultrasound and where available histology of host tissue has allowed detailed phenotypes to be developed . Intraoperative recordings of phenotype have also been noted. Genotyping of specific patterns groupings of corneal developmental anomaly phenotypes. Retrospective analysis of clnical outcome with or without surgical intervention. Results Corneal developmental anomalies are best considered in terms of primary corneal disease and secondary corneal disease. The former includes dystophies ( CHED, PPCD and X-L ECD) , corneal dermoids and isolated sclerocornea ( CNA 1 and 2 ).Secondary corneal disease includes secondary to, iridotrabecular anomalies ( eg congenital glaucoma, aniridia, axenfeld -rieger anomaly), kerato-irido-lenticular dysgenesis ( iridolenticular adhesions( Peters type I), failure of lens to form,separate or move away from the cornea). Conclusion Using this classification prognosis for intervention can be shown to be mor successful in primary corneal developmental anomalies. Also by considering groups of patients with similar disease eg primary aphakia, appropriate genotyping can be done eg FOXE3 analysis for children with primary aphakia . More acccurate phenotype allows better clinical classification and ultimately better genotyping of corneal developmental anomalies [source] Short Implants Placed One-Stage in Maxillae and Mandibles: A Retrospective Clinical Study with 1 to 9 Years of Follow-UpCLINICAL IMPLANT DENTISTRY AND RELATED RESEARCH, Issue 1 2007Paulo Maló DDS ABSTRACT Background:, The use of short implants (7,8.5 mm) has historically been associated with lower survival rates than for longer implants. However, recent clinical studies indicate that short implants may support most prosthetic restorations quite adequately, but still clinical documentation is sparse. Purpose:, The purpose of this study was to report on the placement of short Brånemark implants, testing the hypothesis that short implants in atrophied jaws might give similar long-term implant survival rates as longer implants used in larger bone volumes. Materials and Methods:, This retrospective clinical study included 237 consecutively treated patients with 408 short Brånemark implants supporting 151 fixed prostheses. One hundred thirty-one of the implants were 7-mm long, and 277 were 8.5-mm long. Final abutments were delivered at the time of surgery, and final prostheses were delivered 4 to 6 months later. Results:, One hundred and twenty six of the 7-mm implants (96%) have passed the 1-year follow-up; 110 (84%), the 2-year follow-up; and 88 (67%), the 5-year follow-up. Five implants failed in four patients before the 6-month follow-up, giving a cumulative survival rate of 96.2% at 5 years. The average bone resorption was 1 mm (SD=0.6 mm) after the first year and 1.8 mm (SD=0.8 mm) after the fifth year of function. Two hundred sixty nine of the 8.5-mm implants (97%) have passed the 1-year follow-up; 220 (79%), the 2-year follow-up; and 142 (51%), the 5-year follow-up. Eight implants failed in seven patients before the 6-month follow-up, giving a cumulative survival rate of 97.1% at 5 years. The average bone resorption was 1.3 mm (SD=0.8 mm) after the first year and 2.2 mm (SD=0.9 mm) after the fifth year of function. Conclusions:, The cumulative survival rates of 96.2 and 97.1% at 5 years for implants of 7.0- and 8.5-mm length, respectively, indicate that one-stage short Brånemark implants used in both jaws is a viable concept. [source] Report of a Case Receiving Full-Arch Rehabilitation in Both Jaws Using Immediate Implant Loading Protocols: A 1-Year Resonance Frequency Analysis Follow-UpCLINICAL IMPLANT DENTISTRY AND RELATED RESEARCH, Issue 1 2006Michael Portmann DDS ABSTRACT Background:, Immediate occlusal implant loading has been documented as a viable treatment option for various indications. However, documentations related to full-arch rehabilitation are usually limited to treatment of one jaw at a time, thereby leaving the opposing dentition unchanged. Furthermore, clinical documentation using traditional, well-accepted measuring techniques may not be adequate when it comes to short-term evaluation of the success or failure of implants subjected to immediate occlusal loading. Purpose:, The purpose of this case report is to (1) present an implant stability follow-up of a patient receiving an immediate, implant-supported full-arch rehabilitation in both jaws and (2) evaluate the patient's acceptance of this rehabilitation. Materials and Methods:, A 68-year-old patient scheduled for implant treatment was selected for an immediate implant loading protocol in both jaws. During two surgical events 3 weeks apart, eight maxillary and four mandibular Brånemark System® Mk IV TiUniteTM fixtures (Nobel Biocare AB, Göteborg, Sweden) were inserted and subsequently used to immediately support a cross-arch fixed prosthesis in the maxilla and a bar-retained overdenture in the mandible. Implant stability was recorded from the day of surgery periodically during a 1-year follow-up using resonance frequency analysis (RFA). Results:, At the 1-year follow-up, based on clinical, RFA, and radiographic evaluations, all implants and the reconstructions were classified as successful. All maxillary implants showed a decrease in the implant stability quotient (ISQ) value from the measurement at the time of surgery to the first follow-up, whereas two of four mandibular implants revealed an initial drop in stability. Irrespective of a specific ISQ level measured at implant surgery (ISQ range 53,74) and despite an initial decrease in stability, measurements recorded at the 12-month follow-up indicated similar stability levels for all maxillary implants (ISQ range 64,68) or the group of mandibular implants (ISQ range 72,75) but with a higher ISQ level for mandibular implants. Furthermore, the patient's acceptance of the immediate full-arch rehabilitation in both jaws was high. Conclusions:, The present case report demonstrates that a slightly staged approach for full-arch rehabilitation in both jaws using immediate implant loading protocols is a realistic treatment option. Furthermore, RFA follow-up indicates that immediately occlusally loaded implants placed in reduced bone quality and quantity are more prone to loose stability in the early healing period compared with implants placed in dense bone quality. [source] | ||||||||||