Implementation of a Clinical Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department

Abstract:A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

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Computer-Aided Diagnosis in Jaundice: Comparison of Knowledge-based and Probabilistic Approaches

Methods of Information in Medicine ◽

10.1055/s-0038-1634634 ◽

1996 ◽

Vol 35 (01) ◽

pp. 41-51 ◽

Cited By ~ 3

Author(s):

F. Molino ◽

D. Furia ◽

F. Bar ◽

S. Battista ◽

N. Cappello ◽

...

Keyword(s):

Clinical Presentation ◽

Clinical Information ◽

Diagnostic Value ◽

Clinical Findings ◽

Clinical Documentation ◽

Data Set ◽

Knowledge Based ◽

Number Of Patients ◽

Support Tools ◽

Aided Diagnosis

AbstractThe study reported in this paper is aimed at evaluating the effectiveness of a knowledge-based expert system (ICTERUS) in diagnosing jaundiced patients, compared with a statistical system based on probabilistic concepts (TRIAL). The performances of both systems have been evaluated using the same set of data in the same number of patients. Both systems are spin-off products of the European project Euricterus, an EC-COMACBME Project designed to document the occurrence and diagnostic value of clinical findings in the clinical presentation of jaundice in Europe, and have been developed as decision-making tools for the identification of the cause of jaundice based only on clinical information and routine investigations. Two groups of jaundiced patients were studied, including 500 (retrospective sample) and 100 (prospective sample) subjects, respectively. All patients were independently submitted to both decision-support tools. The input of both systems was the data set agreed within the Euricterus Project. The performances of both systems were evaluated with respect to the reference diagnoses provided by experts on the basis of the full clinical documentation. Results indicate that both systems are clinically reliable, although the diagnostic prediction provided by the knowledge-based approach is slightly better.

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TO DETERMINE THE ROLE OF CA125 IN THE DIAGNOSIS OF ACUTE APPENDICITIS

International Journal of Medical and Biomedical Studies ◽

10.32553/ijmbs.v4i7.1276 ◽

2020 ◽

Vol 4 (7) ◽

Author(s):

Vinod Kumar ◽

Bhupen Songra ◽

Richa Jain ◽

Deeksha Mehta

Keyword(s):

Acute Appendicitis ◽

Clinical Diagnosis ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Ca 125 ◽

Care Hospital ◽

Serum Samples ◽

Roc Curve Analysis ◽

Surgery Department

Background: the present study was under taken to determine the role of CA-125 in the diagnosis of acute appendicitis (AA), to prevent its complications and also in preventing negative appendicectomies in tertiary care hospital. Methods: The study was conducted at a tertiary care and research center between 01/03/2018 to 30/06/2019. Patients admitted to the surgery department with diagnosis of AA were considered for the study. After informed consent, a, standardized history was obtained as a case Performa. Serum samples from all the cases with clinical diagnosis of AA were obtained and stored. Only the cases with histopathologically approved AA were included in the study. Cases operated for clinical diagnosis of AA, but not histopathologically proven AA was not included in the study. CA125 levels in cases with definitive diagnosis of AA were measured. Results: In present study, ROC curve analysis revealed the sensitivity of 87.27 % and specificity of 90.91 % when the CA 125 cut-off value of > 16.8 was taken to diagnose acute appendicitis. AUC was 0.911 with a standard error of 0.0292. Conclusion: In this study we have observed that CA125 showed a positive correlation with acute appendicitis, that was statistically not significant (P>0.05). We didn’t evaluate the correlation with the disease severity. We consider that CA125 can be used as a marker in acute appendicitis cases although further research is still needed. Keywords: CA125, Acute Appendicitis, Surgery.

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