Record Keeping (record + keeping)

Distribution by Scientific Domains


Selected Abstracts


Putting flesh and polish on autoimmune hepatitis and moving the disease of exclusion to inclusion,

HEPATOLOGY, Issue 4 2010
Albert J. Czaja
Autoimmune hepatitis emerged during an era when concepts of neonatal immune tolerance, clonal selection of lymphocytes, and "forbidden clones" of activated immune cells were forming. The diagnosis had to be deduced from circumstantial evidence and by exclusion of other conditions. The goals of this review are to demonstrate how a clinician nonscientist can contribute to the maturation of autoimmune hepatitis and to illustrate the principles of clinical investigation that can be applied broadly to other projects. Autoimmune hepatitis initially had to be distinguished from other diseases, and improvements in the tests for viral and immune markers were instrumental in this regard. Diversification of the clinical phenotype to accommodate acute severe, asymptomatic, elderly, and variant forms enhanced the pertinence of the disease, and the formation of the International Autoimmune Hepatitis Group standardized the diagnosis, interconnected investigators, and promoted global acceptance of the condition. Subsequent studies refined current corticosteroid-based therapies, identified prognostic markers, assessed genetic predispositions, explored new pharmacological agents, and forecast the emergence of cellular and molecular interventions. Good fortune, stimulating mentors, career dedication, practical goal selection, protocol compliance, compulsive record keeping, personal resilience, and strong collaborations were the bases for progress. Autoimmune hepatitis exemplifies an evolutionary process in the science of autoimmunity and the people committed to its study. Lessons derived from this experience can be far-reaching. (HEPATOLOGY 2010;52:1177-1184) [source]


Taking Stock at Quantum University,/INVENTAIRE À L'UNIVERSITÉ QUANTUM

ACCOUNTING PERSPECTIVES, Issue 4 2007
Gary Grudnitski
ABSTRACT This case describes the operations and procedures of a major university's athletic equipment room. It details the functions of requisitioning, purchasing, and receiving of equipment and gear used by the university's sports teams; and the custody, management, and record keeping of these items. On the basis of this description, the student is asked to prepare a two-part report. In the first part of the report the student should identify the weaknesses and associated risks that existed in the operations of the equipment room and its inventory of athletic equipment, gear, and clothing. Furthermore, instances in the case that provide evidence of these weaknesses and risks should also be reported. Upon receiving feedback on the adequacy of the first part of the report, the student in the second part of the report should delineate the controls that might be implemented to address these weaknesses and mitigate their associated risks. RÉSUMÉ Le cas élaboré par les auteurs contient une description du fonctionnement et des méthodes de gestion de la salle de matériel de sport d'une grande université. Les fonctions de demande d'achat, d'achat et de réception du matériel et des appareils utilisés par les équipes sportives de l'université y sont décrites avec précision, de même que celles de la garde et de la gestion de ce matériel ainsi que de la tenue des registres de stock. À partir de cette description, l'étudiant est appelé à préparer un rapport en deux volets. Dans le premier volet doivent être relevés les faiblesses que présentent le fonctionnement de la salle de matériel de sport et la tenue de l'inventaire du matériel, des appareils et des vêtements de sport, et les risques qui y sont associés. Les données du cas établissant l'existence de ces faiblesses et de ces risques doivent aussi figurer dans le rapport. Lorsque l'étudiant reçoit une appréciation de la pertinence du premier volet du rapport, il doit, dans le second volet, décrire les contrôles qui pourraient être mis en ,uvre pour combler ces faiblesses et atténuer les risques qui y sont associés. [source]


Insights into creation and use of prescribing documentation in the hospital medical record

JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2005
Mary P. Tully PhD MRPharmS
Abstract Rationale, aims and objectives, Extraction of prescribing data from medical records is a common, albeit flawed, research method. Yet little is known about the processes that result in those data. This study explores the creation and use of prescribing documentation in the medical record, from the perspective of the hospital doctors who both create and use it. Methods, Thirty-six hospital doctors were purposively selected for qualitative interviews, giving a maximum variability sample of grades of doctors across the range of major medical specialty areas and medical teams at a large teaching hospital in England. Results, The findings suggest a number of reasons why hospital doctors fail to record prescribing decisions in the medical record. There was no set standard, record keeping was not formally taught and the hurried environment of the ward gave little time for documentation. The doctors also acknowledged that there was no need for completeness, as colleagues would be able to ,fill in the gaps' via an inferential process. ,Assumptions ,were ,made ,and ,although ,this ,was ,not ,seen ,as ,ideal, it was recognized as necessary if work was to be done efficiently. Conclusion, These results reinforce the suggestion that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge. This has profound implications for those without that insider knowledge who are using medical records for research purposes. Funding, This work was funded by a North West Regional National Health Service Postdoctoral Fellowship. [source]


Improving general practitioner records in France by a two-round medical audit

JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2002
Jean Brami MD
Abstract Rationale, aims and objectives,The effectiveness of clinical audits in changing the practice of health care professionals is a moot point. Methods of implementation impinge directly upon outcomes. We investigated whether a network of local opinion leaders could contribute towards a successful audit. Our objectives were to: (i) bring about an improvement in record keeping in general practice; and (ii) increase GPs' awareness of medical evaluation. Methods,The GPs were recruited by local opinion leaders who had been briefed by the French National Agency for Accreditation and Evaluation in Health Care (ANAES, formerly ANDEM). On a given day (first round of the audit) they were invited to examine whether the medical records of their 10 first patients met 13 set criteria. Overall results were analysed by ANAES. Each GP was informed of how well they had fared compared with the regional and national averages and was provided with a standard set of recommendations. Anonymity was ensured by the local leaders. A second round was conducted 6 months later. Results,A total of 244 GPs took part in both rounds of the audit; 32 dropped out after the first round. Their results were of a significantly lower standard. A significant improvement in results (P < 0.025) was recorded between the two rounds for all 13 criteria of the questionnaire. Overall scores improved between the two rounds for 69% of the GPs and improved above average for 49%. The greatest scatter in results was noted for items relating to medical history rather than to personal identity (administrative data). Conclusions,Self-assessment can help improve general standards of medical record keeping. A network of local opinion leaders, briefed by a national agency whose mission is to promote quality improvement in health care, seems to be an effective means of inducing participation in self-assessment. [source]


Establishing a standardized dental record-keeping system for a small investigational colony of rhesus monkeys (Macaca mulatta)

JOURNAL OF MEDICAL PRIMATOLOGY, Issue 2008
B.W. Gibson
Abstract Background, Dental hygiene is becoming an increasingly important component of quality health care for laboratory animals, especially non-human primates (NHPs). One key to a successful health care program is an effective and efficient record-keeping system. Methods, To standardize a dental hygiene program for a small colony of NHPs, we developed a dental recording chart specific for rhesus monkeys. This dental chart was developed using the modified Triadan system. This system numbers teeth across species according to location. Results, An illustrative case report was presented to demonstrate the accurate record keeping and spatial relationship generated from this Old World NHP dental chart design. Conclusion, The development and implementation of a standardized dental chart, as part of a dental hygiene program will help minimize variables that may affect research data. [source]


The Evolutionary Forms of the Religious Life: A Cross-Cultural, Quantitative Analysis

AMERICAN ANTHROPOLOGIST, Issue 4 2008
STEPHEN K. SANDERSON
ABSTRACT, Previous cross-cultural studies of religion's evolution that employed Swanson's High Gods measure are plagued by methodological difficulties, especially the lack of proper statistical controls. Here, we attempted to rectify this, using the Standard Cross-Cultural Sample to test five hypotheses employing multivariate statistical techniques. Results provided weak support for Swanson's Sovereign Groups hypothesis concerning High Gods and also limited support for a previously unexplored factor: writing and record keeping. In phase two of the study, we introduced a new measure, the Stage of Religious Evolution, based on Anthony Wallace's typology. When this new dependent variable was substituted for High Gods, much stronger results were obtained. The best predictors of Stage of Religious Evolution were mode of subsistence economy, writing and record keeping, and total population size. These findings allowed us to construct a new evolutionary interpretation of the development of different modes of religious life. [source]


Utilizing audit to evaluate improvements in continuous veno-venous haemofiltration practices in intensive therapy unit

NURSING IN CRITICAL CARE, Issue 4 2006
Annette Richardson
Abstract Continuous veno-venous haemofiltration (CVVH) is used regularly in the management of acute renal failure in intensive therapy unit (ITU). A three-staged approach was undertaken involving two audits of practice to improve CVVH record keeping in a 15-bedded cardiac ITU. An initial baseline audit identified a number of areas for improvement in practice. The areas for improvement were implemented then a second audit was repeated. The improvements and practice changes included the dissemination of audit findings to the multidisciplinary team, redesigning the prescription chart to a more user-friendly format and the development of a competency-based CVVH workbook. This nurse-led project demonstrated how positive outcomes and improvements could be achieved with record keeping across the multidisciplinary ITU team. [source]


Stream Restoration in the Upper Midwest, U.S.A.

RESTORATION ECOLOGY, Issue 4 2006
Gretchen G. Alexander
Abstract Restoration activities intended to improve the condition of streams and rivers are widespread throughout the Upper Midwest, U.S.A. As with other regions, however, little information exists regarding types of activities and their effectiveness. We developed a database of 1,345 stream restoration projects implemented from the years 1970 to 2004 for the states of Michigan, Ohio, and Wisconsin in order to analyze regional trends in goals, presence of monitoring, spatial distribution, size, and cost of river restoration projects. We found that data on individual projects were fragmented across multiple federal, state, and county agencies, as well as nonprofit groups and consulting firms. The most common restoration goals reported for this region were in-stream habitat improvement, bank stabilization, water-quality management, and dam removal. The former two were most common in Michigan and Wisconsin, where salmonid fisheries enhancement appeared to be an important concern, whereas water-quality management was most frequent in Ohio. The most common restoration activities were the use of sand traps and riprap, and other common activities were related to the improvement of fish habitat. The median cost was $12,957 for projects with cost data, and total expenditures since 1990 were estimated at $444 million. Over time, the cost of individual projects has increased, whereas the median size has decreased, suggesting that restoration resources are being spent on smaller, more localized, and more expensive projects. Only 11% of data records indicated that monitoring was performed, and more expensive projects were more likely to be monitored. Standardization of monitoring and record keeping and dissemination of findings are urgently needed to ensure that dollars are well spent and restoration effectiveness is maximized. [source]


Defense of Breast Cancer Malpractice Claims

THE BREAST JOURNAL, Issue 2 2001
FACOG, Samuel Zylstra MD
Abstract: The goal of this study was to determine whether factors associated with the successful defense and cost of malpractice cases involving the failure to diagnose breast cancer could be identified in medical and legal records. Secondary goals were to develop a multidisciplinary clinical algorithm utilizing National Comprehensive Cancer Network (NCCN) practice guidelines with practitioner risk management strategies. Physician deviations from these guidelines were tracked to identify high-risk areas in the diagnosis of breast cancer. A multidisciplinary clinical algorithm was introduced and practitioner risk management issues were addressed. In this study specific medical, legal, and cost factors were retrospectively abstracted and analyzed to identify associations between medical and legal factors and medicolegal outcome. ProMutual handled 156 malpractice cases involving breast cancer between January 22, 1986, and November 20, 1997. Of the total, 124 cases involving 212 defendants were closed. The closed cases were analyzed, using multivariable stepwise logistic and linear regression, to identify associations between clinical factors and case outcome. Women's health practitioners (WHPs), including obstetrician-gynecologists (OB-GYNs), family medicine, and internal medicine clinicians, were the largest group of defendants (97). Others included radiologists (43), surgeons (33), and pathologists (3). OB-GYNs accounted for 31% of these defendants, with a cost of more than $16 million. The greatest number of specialists represented in the open cases were radiologists, with 38% of the total. The defense model predicts that the probability of successful defense is lessened with inadequate record keeping, a patient that has metastasis and is alive, and a delay in diagnosis of 12 months or more. The overall indemnity model predicts a higher indemnity with the spread of disease at the time of evaluation, a patient who has metastasis and is alive, and a date of occurence closer to the present. Indemnity is less in patients who have had a lymph node dissection, who have died, or who are alive without metastasis. The WHP model predicts an increased overall indemnity with the spread of disease at the time of evaluation and the presence of a mass without pain. Indemnity decreases with a history of pregnancy, absence of presenting symptoms, or presentation with pain with or without a mass, and the performance of a lymph node dissection. [source]


Quality of clinical notes for vascular surgery admissions: A CRABEL score review

ANZ JOURNAL OF SURGERY, Issue 7-8 2009
Jun Suh
Abstract Aim:, To compare the quality of patient notes between acute and elective admissions in vascular surgery. Method:, Patient notes from the 50 most recent acute and elective admissions on a vascular surgical unit were reviewed using the CRABEL score. Points for quality of record keeping were awarded in four categories: Initial Clerking, Subsequent Entries, Consent and Discharge Summary. Total scores were calculated as a percentage. One hundred per cent represents the minimum quality standard expected. Overall CRABEL scores were compared for differences in the quality of note keeping between acute and elective admissions. Further analysis identified areas that need improvement. Results:, The mean CRABEL score for acute admissions was 79.2% (77.0,81.3, 95% C.I.) compared to 81.3% (78.8,83.8, 95% C.I.) for elective admissions (t -test P= n.s.). When the individual categories were analysed no statistically significant difference was observed between the two groups for ,Subsequent Entries' and ,Consent' sections (t -test p= n.s.). ,Initial Clerking' category scored significantly better for elective 16.3 out of 20 (15.7,16.9, 95% C.I.) admissions compared to acute admissions 14.6 out of 20 (13.9,15.3, 95% C.I.), (t -test P= 0.00063). ,Discharge Summary' section also scored significantly better for elective admissions 9.9 out of 10 (9.9,10.0, 95% C.I.) compared to acute admissions 9.6 out of 10 (9.3,9.9, 95% C.I.), (t -test P= 0.040). Conclusion:, There was no statistically significant difference in the overall quality of written patient notes between acute and elective admissions, however ,Initial Clerking' and ,Discharge Summary' were better documented for elective admissions. Both acute and elective admissions were observed to have substandard quality of record keeping. [source]


AN AUDIT OF OPERATIVE NOTES: FACTS AND WAYS TO IMPROVE,

ANZ JOURNAL OF SURGERY, Issue 9 2008
Liviu P. Lefter
Background: Accurate operation record keeping is an important element of risk management. Handwritten surgical notes are often produced as evidence in medico-legal malpractice cases and incomplete and illegible notes may be a source of weakness in a surgeon's defence. Therefore, we audited the surgical notes in a teaching hospital surgical department. Methods: During 1 week 190 operative notes were audited for patient identity details, preoperative diagnosis, operation title and details, CMB code, postoperative instruction and author of the note. The operative notes were assessed by a medico-legal lawyer and a medical expert to establish level of legibility and usefulness in a virtual court case. Results: Several operative notes were found incomplete (51.57%) missing important information as CMB code (13.68%), patient details (6.8%) preoperative diagnosis (6.31%), operation title (6.31%) and postoperative instruction (14.73%). Overall, only 92 notes were complete. Conclusion: This audit suggests that handwritten surgical notes generate several errors that could lead to confusion when notes are reviewed for further follow up or are produced as evidence in medico-legal disputes. [source]


Motherhood, Resistance and Attention Deficit Disorder: Strategies and Limits,

CANADIAN REVIEW OF SOCIOLOGY/REVUE CANADIENNE DE SOCIOLOGIE, Issue 2 2001
Claudia Malacrida
Étant donné son ambiguïté sur les plans culturel et historique, l'ap-pellation psychiatrique de trouble déficitaire de I'attention (hyperac-tivité) entraîne les mères dans un conflit avec les discours sur l'image de la bonne mère, la normativité familiale, les compétences profes-sionnelles et la notion de risque. L'éude d entretiens avec 34 femmes au Canada et en Angleterre a permis de comprendre, du point de vue des femmes, les mécanismes de la connaissance et du pouvoir qui sous-tendent les relations avec des professionnels de la médecine, de la psychiatrie et de l'éducation. Les mères se sont approprié une vaste gamme de méthodes discursives afin de se présenter elles et leur famille comme des personnes méritantes, louables et cultivées. Elles se sont engagées dans l'examen scrupuleux des méthodes éduca-tionnelles et psychiatriques par l'intermédiaire du bénévolat, de la contribution à la conception de politiques, de la tenue de dossiers et du recours à des témoins externes afin de renforcer leur légitimité. Par ailleurs, de nombreuses femmes se sont engagées dans le jeu de la vérité, ont choisi la confrontation et, finalement, le refus. Toutefois, étant donné que des enfants vulnerables sont en jeu, la capacité des mères a résister véritablement reste limitée. The psychiatric category Attention Deficit Disorder (Hyperactivity), because of its cultural and historical ambiguity, brings mothers into conflict with discourses of good motherhood, family normativity, professional knowledge and risk. Interviews with 34 women in Canada and England were conducted as a way to understand, from women's perspectives, the workings of knowledge and power encountered in dealing with medical, psychiatric and educational professionals. Mothers took up a wide range of discursive practices in attempts to position themselves and their families as worthy, deserving and knowledgeable. They also engaged in scrutiny of educational and psychiatric practice through volunteering, policy contributions, record keeping and using outside witnesses to shore up their legitimacy. As well, many engaged in knowledge/truth games, confrontation and, ultimately, refusal. However, because vulnerable children are at stake, mothers' ability to truly resist remains limited. [source]