scholarly journals 63EXPLORING THE KNOWLEDGE, VIEWS AND EXPERIENCES OF JUNIOR MEDICAL STAFF IN RELATION TO MEDICAL DOCUMENTATION AND CODING IN A TERTIARY TEACHING HOSPITAL

2017 ◽  
Vol 46 (suppl_1) ◽  
pp. i1-i22
Author(s):  
T Singh ◽  
A Bourke ◽  
R Prowse
2016 ◽  
Vol 11 (1) ◽  
pp. 56-64 ◽  
Author(s):  
Alison Dwyer ◽  
John McNeil

Clinical Registries are established to provide a clinically credible means for monitoring and benchmarking healthcare processes and outcomes, to identify areas for improvement, and drive strategies for improving patient care. Clinical Registries are used to assess changes in clinical practice, appropriateness of care and health outcomes over time. The American Heart Association Policy Statement in April 2011 called for expanding the application for existing and future Clinical Registries, with well-designed Clinical Registry programs. Concurrently, in Australia, and similarly within the United States and United Kingdom, there has been an increased focus on performance measurement for quality and patient safety. Within Victoria, the Victorian Clinical Governance Policy Framework outlines clinical effectiveness as one of the four domains of Clinical Governance As Clinical Registries evaluate effectiveness and safety of patient care by measuring patient outcomes compared with peers, the use of Clinical Registries data to improve a health service’s quality of care seems intuitive. A mixed methods approach was utilised, involving (1) semi-structured interviews and (2) documentation audit in this study conducted at Austin Health, a major tertiary teaching hospital in North-Eastern metropolitan Melbourne, affiliated with the University of Melbourne and various research institutes within Austin LifeSciences. Although many studies have highlighted the benefits of data collected via individual Clinical Registries, [5,6] the level of voluntary medical staff participation in Clinical Registries at a health service level is yet to be established. The aim of this study was to document the level of medical staff involvement for Clinical Registries within a major tertiary teaching hospital, and the level of reporting into Quality Committees within the organisation. This study demonstrates that along with a very high level of medical staff participation in Clinical Registries, there is a lack of systematic reporting of Registries data into quality committees beyond unit level, and utilisation of such data to reflect upon practice and drive quality improvement. Abbreviations: CREPS – Centre for Excellence in Patient Safety; CSU – Clinical Services Unit; HOU – Heads of Unit; VASM – Victorian Audit of Surgical Mortality.


2021 ◽  
Vol 30 ◽  
pp. S189
Author(s):  
I. Button ◽  
J. Bradley ◽  
R. Roberts-Thomson ◽  
B. Lorraine

2008 ◽  
Vol 23 (4) ◽  
pp. 423-428 ◽  
Author(s):  
Seung Soo Sheen ◽  
Ji Eun Choi ◽  
Rae Woong Park ◽  
Eun Yub Kim ◽  
Young Ho Lee ◽  
...  

Medicine ◽  
2021 ◽  
Vol 100 (14) ◽  
pp. e25311
Author(s):  
Hsin-I. Shih ◽  
Yi-Ting Huang ◽  
Chih-Chia Hsieh ◽  
Tzu-Ching Sung

2017 ◽  
Vol 07 (03) ◽  
pp. 195-211
Author(s):  
Soumya Ranjan Behera ◽  
Manoranjan Behera ◽  
Sidhartha Das ◽  
Bhabani Prasad Panda ◽  
Saroj Kumar Tripathy ◽  
...  

2021 ◽  
Author(s):  
◽  
Tara Marie Ryton-Malden

<p>Aim: To identify how nurses respond to abnormal physiological observations in the 12 hours prior to a patient having a cardiac arrest. Methods: A descriptive observational design was used to retrospectively review the observation charts and nursing notes of 28 patients who had an in-hospital cardiac arrest, during a 20 month period. This study was performed in a large, tertiary teaching hospital in New Zealand. Key Findings Only one patient met the hospitals minimum standard of four hourly observations and a full set of vital signs were performed on only three patients. The nursing responses were limited to increasing the frequency of observations or informing the doctor. There were few other interventions to treat the abnormality. Eight (32%) patients who had either no response or a partial response to their abnormal physiology did not survive. The nursing documentation demonstrated that abnormal neurological observations were tolerated for significant periods of time and were not acted upon in 62% of these patients. The nursing documentation revealed that the delivery of oxygen was often insufficient to meet the patient's requirements and the medical staff were aware of less than half the patients with abnormal physiology. Discussion removed statement re pt survival: This research identified major deficiencies with recording patient vital signs. If these are not recorded regularly, patient deterioration will be missed and treatment cannot be initiated. Nurses need to respond to abnormal physiology beyond repeating vital signs and informing the medical staff. They are accountable for initiating interventions to prevent further deterioration. Conclusion: The early recognition of patient deterioration and treatment are essential to prevent cardiac arrest. Education strategies are required to improve compliance with recording patient vital signs, communication between nursing and medical staff and how to respond to patient deterioration. The barriers to these must be addressed and solutions sought if patient mortality is to be improved.</p>


2021 ◽  
Vol 5 ◽  
pp. 239920262110627
Author(s):  
Roland Nnaemeka Okoro ◽  
Kasim Abdullahi ◽  
Dauda Ayuba Dayar

Background: Proton-pump inhibitor (PPI) is a widely used medication class globally. Because of its good safety profile, there is a huge likelihood of inappropriate use. Objectives: To determine the prevalence of PPI use and indications, describe its pattern of usage, and identify factors associated with inappropriate prescriptions at a federal tertiary teaching hospital in Maiduguri, Nigeria. Methods: PPI prescriptions were retrospectively assessed in the General Outpatients’ Department (GOPD) and Gastroenterology Unit (GITU) of a teaching hospital. Relevant data for the study were extracted from the patients’ medical records. Chi-square or Fisher’s exact tests where appropriate were used to identify factors associated with inappropriate PPI prescriptions. A p < 0.05 was considered to be significant. Results: PPIs were prescribed to 73.3% (220/300) of patients, while inappropriate prescriptions were noted in 91.4% (201/220) of these patients. Epigastric pain (49.5%) was the most common PPI indication, while omeprazole was the highest prescribed (53.4%). Nearly all inpatients (98.2%), those with epigastric pain (95.7%), and patients who were prescribed intravenous PPIs had more inappropriate PPI prescriptions compared to others. Conclusion: This study revealed a high prevalence of PPI use and inappropriate prescriptions at the study hospital. As a result, these findings highlight the importance PPI-based stewardship program at the study hospital.


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