Accuracy of Healthcare Worker Recall and Medical Record Review for Identifying Infectious Exposures to Hospitalized Patients

2006 ◽  
Vol 27 (7) ◽  
pp. 722-728 ◽  
Author(s):  
M. Aquino ◽  
J. M. Raboud ◽  
A. McGeer ◽  
K. Green ◽  
R. Chow ◽  
...  
Keyword(s):  
Medical Record ◽  
Healthcare Worker ◽  
Medical Records ◽  
Medical Record Review ◽  
Contact Tracing ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Memory Aids ◽  
Record Review

Objective.To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting.Design.Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall.Setting.A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario.Patients.Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts.Results.Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient–HCW pairs were not recorded in patients' medical records.Conclusions.Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

scholarly journals Medical Record Review to Differentiate between Idiopathic Parkinson’s Disease and Parkinsonism: A Danish Record Linkage Study with 10 Years of Follow-Up

2015 ◽  
Vol 2015 ◽  
pp. 1-9 ◽  
Author(s):  
Lene Wermuth ◽  
Xin Cui ◽  
Naomi Greene ◽  
Eva Schernhammer ◽  
Beate Ritz
Keyword(s):  
Medical Record ◽  
Electronic Medical Records ◽  
Clinical Features ◽  
Medical Records ◽  
Chart Review ◽  
Large Population ◽  
Area Under The Curve ◽  
Medical Record Review ◽  
Record Review

Background. The electronic medical records provide new and unprecedented opportunities for large population-based and clinical studies if valid and reliable diagnoses can be obtained, to determine what information is needed to distinguish idiopathic PD from Parkinsonism in electronic medical records.Methods. Chart review of complete medical records of 2,446 patients with a hospital discharge diagnosis of PD, who, between 1996 and 2009, were registered in the Danish National Hospital Register as idiopathic PD. All patients were examined in neurology departments. Clinical features were abstracted from charts to determine Parkinsonian phenotypes and disease course, using predefined criteria for idiopathic PD.Results. Chart review verified that 2,068 (84.5%) patients met criteria for idiopathic PD. The most distinguishing features of idiopathic PD patients were asymmetric onset, and fewer atypical features at onset or follow-up compared to Parkinsonism, and the area under the curve (AUC) for these items alone is moderate (0.74–0.77) and the highest AUC (0.91) was achieved when using all clinical features recorded in addition to PD medication use and a follow-up of 5 years or more.Conclusion. To reduce disease misclassification, information extracted from medical record review with at least 5 years of follow-up after first diagnosis was key to improve diagnostic accuracy.

scholarly journals Diagnosis and treatment of patients with antiphospholipid syndrome: a mixed-method evaluation of care in The Netherlands

2020 ◽  
Vol 4 (2) ◽  
Author(s):  
Mirthe J Klein Haneveld ◽  
Caro H C Lemmen ◽  
Tammo E Brunekreef ◽  
Marc Bijl ◽  
A J Gerard Jansen ◽  
...  
Keyword(s):  
The Netherlands ◽  
Focus Groups ◽  
Medical Record ◽  
Medical Records ◽  
Quantitative Methods ◽  
Medical Record Review ◽  
Anticoagulant Treatment ◽  
Medical Specialists ◽  
Record Review ◽  
Fragmentation Of Care

Abstract Objectives The aims were to gain insight into the care provided to patients with APS in The Netherlands and to identify areas for improvement from the perspective of both patients and medical specialists. Methods APS care was evaluated using qualitative and quantitative methods. Perspectives on APS care were explored using semi-structured interviews with medical specialists, patient focus groups and a cross-sectional, online patient survey. In order to assess current practice, medical records were reviewed retrospectively to collect data on clinical and laboratory manifestations and pharmacological treatment in six Dutch hospitals. Results Fourteen medical specialists were interviewed, 14 patients participated in the focus groups and 79 patients completed the survey. Medical records of 237 patients were reviewed. Medical record review showed that only one-third of patients were diagnosed with APS within 3 months after entering specialist care. The diagnostic approach and management varied between centres and specialists. Almost 10% of all patients and 7% of triple-positive patients with thrombotic APS were not receiving any anticoagulant treatment at the time of medical record review. Correspondingly, poor recognition and fragmentation of care were reported as the main problems by medical specialists. Additionally, patients reported the lack of accessible, reliable patient education, psychosocial support and trust in physicians as important points for improvement. Conclusion Delayed diagnosis, variability in management strategies and fragmentation of care were important limitations of APS care identified in this study. A remarkable 10% of patients did not receive any anticoagulant treatment.

scholarly journals Validity and reliability of a medical record review method identifying transitional patient safety incidents in merged primary and secondary care patients’ records

BMJ Open ◽  
2018 ◽  
Vol 8 (8) ◽  
pp. e018576 ◽  
Author(s):  
Marije A van Melle ◽  
Dorien L M Zwart ◽  
Judith M Poldervaart ◽  
Otto Jan Verkerk ◽  
Maaike Langelaan ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Medical Records ◽  
Secondary Care ◽  
Information Transfer ◽  
Safety Issue ◽  
Medical Center ◽  
Medical Record Review ◽  
Measurement Tool ◽  
Record Review

ObjectiveInadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.DesignA retrospective medical record review study.Settings and participantsCombined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs.OutcomesTo assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.ResultsThe reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3–28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen’s kappa −0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.ConclusionThe reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.

scholarly journals ReCAP: Detection of Potentially Avoidable Harm in Oncology From Patient Medical Records

2016 ◽  
Vol 12 (2) ◽  
pp. 178-179 ◽  
Author(s):  
Allison Lipitz-Snyderman ◽  
Saul N. Weingart ◽  
Christopher Anderson ◽  
Andrew S. Epstein ◽  
Aileen Killen ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Medical Record ◽  
Cancer Care ◽  
Medical Records ◽  
Screening Tool ◽  
Real Life ◽  
Risk Groups ◽  
Medical Record Review ◽  
Efficient Detection ◽  
Record Review

QUESTION ASKED: Although medical record–based measurement of adverse events (AEs) associated with cancer care is desirable, condition-specific triggers in oncology care are needed. We sought to develop a screening tool to facilitate efficient detection of AEs across settings of cancer care via medical record review. We hope to use this tool to understand the frequency, spectrum, and preventability of AEs with the goal of helping improve the quality and safety of cancer care. SUMMARY ANSWER: We developed a cancer-specific screening tool to help identify candidate preventable AEs that occur during cancer care from patients’ medical records. Our oncology screening tool consists of 76 triggers—readily identifiable findings to screen for possible AEs that occur during cancer care ( Table 1 ). METHODS: We sought to develop a screening tool to facilitate the detection of AEs across settings of cancer care via medical record review. We obtained structured and unstructured input from clinical experts to develop our tool, using a modified Delphi process. BIAS, CONFOUNDING FACTOR(S), DRAWBACKS: Our oncology tool requires further evaluation in order to understand its usefulness for population-based assessments of AEs in oncology and quality improvement. REAL-LIFE IMPLICATIONS: Information obtained from structured record reviews using an oncology trigger tool could help to prioritize quality improvement activities, identify high-risk groups, and generate cancer-focused quality measures. Ultimately, the goals of this work are to prevent AEs and allow timely, automated identification of these events so that clinicians can intervene promptly to improve patient outcomes. [Table: see text]

Abstract P270: Automating Processes to Expedite Medical Record Review in Research

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
K M Reeder ◽  
Edward Ellerbeck ◽  
Marilyn Werkowitch ◽  
N. Nazir ◽  
B. Waltrip ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Emergency Room ◽  
Medical Record ◽  
Medical Records ◽  
Chart Review ◽  
Medical Record Review ◽  
Automated System ◽  
Emergency Room Visits ◽  
Automated Method ◽  
Record Review

Problem. Heart failure (HF) clinical trials often use medical record review data to determine HF related hospital events, such as emergency room visits and readmissions. However, reviewing medical records for each hospital event can be daunting. The purpose of this project was to expedite medical record review processes using an automated method for identifying potential HF related hospital events. Methods. A stepwise procedure was developed for obtaining electronic information of all consented HF clinical trial participants' hospital events. First, an electronic list of all study participants was generated from a study data base and electronically sent to the Medical Records department each month. Next, a list of all emergency room visits and hospitalizations, including admission and discharge dates, discharge disposition, and diagnosis and procedure codes was electronically generated by the Medical Records department. A trained cardiovascular research nurse reviewed the abstracted coding and billing data for each hospital event and identified specific codes potentially related to HF. Last, hospital events identified as meeting specific criteria were included in the medical record review. Results. Using the automated system, a total of 294 hospital events for 125 subjects were obtained from the Medical Records department during the initial 2 years of the clinical trial. Of these, 85 (29%) hospital events were identified as needing to undergo chart review. Thirty-three (39%) of the 85 charts that underwent blinded review were identified as being HF related hospital events. Conclusions. Automating procedures for obtaining hospital event information expedited both the systematic data review and chart review processes. In this study, combined use of automated processes for obtaining hospital event data and nurse review reduced the number of charts requiring blinded review by nearly 60%.

Adherence to Treatment In Patients with Chronic Myelogenous Leukemia During a 10-Year Time Period: A Medical Record Review.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1235-1235 ◽  
Author(s):  
Marianne Ulcickas Yood ◽  
Susan A Oliveria ◽  
Ishan Hirji ◽  
Mark Cziraky ◽  
Catherine Davis
Keyword(s):  
Medical Record ◽  
Myelogenous Leukemia ◽  
Medical Record Review ◽  
Imatinib Treatment ◽  
Treatment Information ◽  
Real World Setting ◽  
Time Period ◽  
One Year ◽  
Record Review

Abstract Abstract 1235 Introduction: Over the past 10 years, oral treatment options for chronic myelogenous leukemia (CML) have provided patients autonomy over treatment administration. Low adherence to long-term maintenance therapy is a known challenge in a number of chronic diseases. The correlation between poor adherence and poor clinical outcomes has been previously demonstrated among CML patients in a clinical study setting. Few studies have evaluated adherence to CML treatments in a real-world setting and none have assessed treatment and adherence trends over time in a contemporary cohort of patients. Further, no studies have used medical record review to obtain comprehensive CML diagnosis and treatment information. Method: Medical and pharmacy claims from HealthCore Integrated Research Database™ (8.5 million covered US lives during study time period) were used to identify patients with CML (2001 – 2005). Review of medical records validated diagnosis and treatment exposure. Currently, additional data are being collected on this cohort to extend follow-up through 2010, and expand the number of CML patients to include data on the newer CML treatments. To measure adherence we used medication possession ratio (MPR) (number of days' supply of prescription divided by 365) and treatment interruptions (TI) (failure to refill prescription within 30 days of end of supply from previous prescription or clinician-directed discontinuation). For the current analysis, adherence to imatinib treatment was assessed for one year following treatment initiation. Result: In the initial study time frame (2001-2005), during which imatinib was indicated as first-line treatment, 216 CML patients treated with imatinib were identified. Mean age at imatinib initiation was 51 years and 42.6% were female. Fifty-one percent of patients had a MPR <85% for the one year period after imatinib initiation and 57% of patients experienced at least one TI during the follow up. Conclusion: Our preliminary findings indicate that adherence to imatinib treatment is low in CML patients for the time period studied. This is the first study to use medical record review to validate exposure and adherence by obtaining comprehensive imatinib treatment information on CML patients in a real-world setting and indicates that adherence may be even lower than previously reported. Adherence data from ongoing analyses which includes longer patient follow-up (up to 10 years) and second-generation tyrosine-kinase inhibitors will be presented. Disclosures: Hirji: Bristol-Myers Squibb: Employment. Davis:Bristol-Myers Squibb: Employment.

Comorbidities and Conmedication Use In Patients with Chronic Myelogenous Leukemia.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 4492-4492
Author(s):  
Susan A Oliveria ◽  
Marianne Ulcickas Yood ◽  
Ishan Hirji ◽  
Mark Cziraky ◽  
Catherine Davis
Keyword(s):  
Medical Record ◽  
Complete Information ◽  
Myelogenous Leukemia ◽  
Medical Record Review ◽  
Research Database ◽  
Pharmacy Claims ◽  
One Year ◽  
The One ◽  
Record Review

Abstract Abstract 4492 Introduction: Few studies have evaluated the presence of comorbidities and the complexity of conmedication among CML patients in the real-world setting. No studies have used automated claims and medical record review to obtain comprehensive CML diagnosis, treatment, comorbidity, and conmedication information. Methods: Medical and pharmacy claims from HealthCore Integrated Research Database™ (8.5 million covered US lives during study time period) were used to identify patients with CML (2001 – 2005). Information on comorbidities and conmedications was obtained using claims data supplemented with medical record review. For the current analysis, conmedication use and the presence of comorbidities were assessed for one year following imatinib initiation. Results: Two hundred and sixteen CML patients treated with imatinib were included in this analysis. Mean age at imatinib initiation was 51 years and 42.6% were female. The mean number of unique medications for treated patients was 19 (median = 9) in the one-year follow-up. Of all medications prescribed within 1-year of CML treatment initiation, approximately 40% had dosing restrictions (i.e. administration required with/without meals) and dosing of more than once per day. The proportion of patients experiencing 1, 2, 3, and 4+ comorbidities was 22%, 16%, 17%, and 29%, respectively. Analyses were also conducted to explore the complexity (based on dosing guidelines and intake restrictions) of each medication and specific comorbidities. Thirty-four percent % of the conmedications had no intake restrictions while 11% had specific intake restrictions (e.g. take on empty stomach) and 15% had dosing guidelines of more than once per day. Forty-one percent of conmedications had both dosing restrictions and dosing of more than once per day. Conclusion: In addition to their CML diagnosis, patients experience a number of other comorbidities, some of which require complex management regimens. This is the first study to use medical record review to validate exposure and CML diagnosis and use claims and medical record review to obtain comprehensive information on comorbidities and conmedications. Additional data are being collected (and will be presented) on this cohort to extend follow-up through 2010, expand the number of CML patients included, and obtain complete information on all CML treatments and comorbidities. Disclosures: Hirji: Bristol-Myers Squibb: Employment. Davis:Bristol-Myers Squibb: Employment.

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