scholarly journals 883 A Closed-Loop Audit to Improve Admissions Documentation in A Busy ENT Department

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A Connelly ◽  
K Law ◽  
A Williamson
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Closed Loop ◽  
Vital Signs ◽  
P Value ◽  
Medication History ◽  
Admission Source ◽  
Effective Care ◽  
User Friendly ◽  
Pro Forma

Abstract Aim Accurate and thorough admissions documentation is crucial for patient safety and effective care. We amended the admissions pro-forma used on a busy adult ENT ward to improve adherence to a modified version of Royal College of Surgeons of England guidelines. Method Baseline documentation of the 25 parameters of interest was assessed using electronic medical records for all emergency and pre-operative admissions over a 4-week period (n = 75). A new pro-forma was introduced, and the documentation over the following 4 weeks (n = 75) was assessed in the same way. Statistical analysis was done using Excel and RStudio (z-test for two proportions, p-value ≤ 0.05). Results The two groups were similar in age, gender, length of stay, and presenting complaint. The new pro-forma was completed for more admissions than the prior version (91% vs 77%) and resulted in documentation improvements in 19 out of 25 parameters. 9 of these were statistically significant, including initial vital signs and differential diagnosis. Parameters that improved, but not significantly, include admission source, medication history, and cognitive assessment. Across the 8 weeks, using a pro-forma (n = 126) significantly improved documentation of 11 parameters compared to freehand clerking (n = 24). Conclusions Adequate documentation at admission can help with immediate patient care, and act as a point of reference during extended stays. We were able to increase use of a pro-forma and produce meaningful documentation improvements quickly. Further work is required to assess why certain parameters are infrequently completed, and how future pro-forma iterations can become more user-friendly.

Perspectives on Electronic Prescribing and Terminologies

2013 ◽  
pp. e370-e373
Author(s):  
David Liebovitz
Keyword(s):  
Patient Safety ◽  
Electronic Medical Records ◽  
Medical Records ◽  
International Classification Of Diseases ◽  
Population Based ◽  
Electronic Prescribing ◽  
Medication History ◽  
Diagnosis Codes ◽  
Classification Of Diseases ◽  
Potential Benefits

Electronic medical records provide potential benefits and also drawbacks. Potential benefits include increased patient safety and efficiency. Potential drawbacks include newly introduced errors and diminished workflow efficiency. In the patient safety context, medication errors account for significant patient harm. Electronic prescribing (e-prescribing) offers the promise of automated drug interaction and dosage verification. In addition, the process of enabling e-prescriptions also provides access to an often unrecognized benefit, that of viewing the dispensed medication history. This information is often critical to understanding patient symptoms. Obtaining significant value from electronic medical records requires use of standardized terminology for both targeted decision support and population-based management. Further, generating documentation for a billable encounter requires usage of proper codes. The emergence of International Classification of Diseases (ICD)-10 holds promise in facilitating identification of a more precise patient code while also presenting drawbacks given its complexity. This article will focus on elements of e-prescribing and use of structured chart content, including diagnosis codes as they relate to physician office practices.

scholarly journals Clinician-Dermatopathologist Communication via the Requisition Form in the Era of Electronic Medical Records: A Review of the Literature

2020 ◽  
Vol 4 (1) ◽  
pp. 15-22
Author(s):  
Haley Danielle Heibel ◽  
Clay J. Cockerell
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
English Language ◽  
Formal Education ◽  
Clinical Information ◽  
Cost Effective ◽  
Work Flow ◽  
Review Of The Literature ◽  
Study Designs ◽  
User Friendly

Background:  There are shortcomings in the quality and accuracy of submitted clinical information on skin biopsy requisition forms (SBRFs).  Most SBRFs are completed via electronic medical records (EMR), and the effect of this on the work flow and the quality of submitted clinical information must be evaluated to identify targets in clinician-dermatopathologist communication for improvement.Objective: This review of the literature explored how SBRFs are currently handled by clinicians in the context of EMR, barriers to effective clinician-dermatopathologist communication, and suggestions for improvement.Methods: A literature search was conducted on Medline, Cinahl, and Scopus including the keywords of dermatology*, dermapatholog*, dermatopathology*, and requisition*.  20 articles were retrieved.  17 articles were included from this search and from cross-referencing articles.Results:  This review reaffirmed the inadequacy of clinical information provided to dermatopathologists.  Standardization of and formal education in completing SBRFs, along with dermatopathologist access to information and images via shared EMR may improve histopathologic interpretation of specimens and allow for cost-effective patient care.Limitations: This review was restricted to the English language.  Previous studies have primarily been retrospective study designs and survey studies.Conclusion: The development of user-friendly standardized SBRFs with validated criteria are necessary.  Clinician awareness of how to appropriately convey information and terminology on the SBRF may significantly improve the work flow of both clinicians and dermatopathologists and patient outcomes.

scholarly journals Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Development of a Tool by Adapted Delphi Procedure

10.2196/14483 ◽  
2020 ◽  
Vol 8 (3) ◽  
pp. e14483
Author(s):  
Leandra Falck ◽  
Marco Zoller ◽  
Thomas Rosemann ◽  
Nahara Anani Martínez-González ◽  
Corinne Chmiel
Keyword(s):  
Primary Care ◽  
Chronic Diseases ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Chronic Conditions ◽  
Evidence Based ◽  
Term Care ◽  
Delphi Procedure ◽  
User Friendly

Background Long-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists. Objective The aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR. Methods We used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators’ utility in practice and summarized them into a user-friendly layout. Results This multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs. Conclusions Our generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.

scholarly journals At the dawn of winter: comparing COVID-19 and influenza presentation and trajectory

2020 ◽  
Author(s):  
Anat Reiner Benaim ◽  
Jonathan Aryeh Sobel ◽  
Ronit Almog ◽  
Snir Lugassy ◽  
Tsviel Ben Shabbat ◽  
...  
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Acute Respiratory Infection ◽  
White Blood Cells ◽  
Vital Signs ◽  
White Blood Count ◽  
Respiratory Illnesses ◽  
Disease Trajectory ◽  
Severe Acute Respiratory Infection ◽  
Comorbidity Burden

BackgroundCOVID-19 is a newly recognized illness with a predominantly respiratory presentation. As winter approaches in the northern hemisphere, it is important to characterize the differences in disease presentation and trajectory between COVID-19 patients and other patients with common respiratory illnesses. These differences can enhance knowledge of pathogenesis and help in guiding treatment.MethodsData from electronic medical records were obtained from individuals admitted with respiratory illnesses to Rambam Health Care Campus, Haifa, Israel, between October 1st, 2014 and September 1st, 2020. Four groups of patients were defined: COVID-19 (693), influenza (1,612), severe acute respiratory infection (SARI) (2,292) and Others (4,054). The variable analyzed include demographics (7), vital signs (8), lab tests (38), and comorbidities (15) from a total of 8,651 hospitalized adult patients. Statistical analysis was performed on biomarkers measured at admission and for their disease trajectory in the first 48 hours of hospitalization, and on comorobidity prevalence.ResultsCOVID-19 patients were overall younger in age and had higher body mass index, compared to influenza and SARI. Comorbidity burden was lower in the COVID-19 group compared to influenza and SARI. Severely- and moderately-ill COVID-19 patients older than 65 years of age suffered higher rate of in-hospital mortality compared to hospitalized influenza patients. At admission, white blood cells and neutrophils were lower among COVID-19 patients compared to influenza and SARI patients, while pulse rate and lymphoctye percentage were higher. Trajectories of variables during the first two days of hospitalization revealed that white blood count, neutrophils percentage and glucose in blood increased among COVID-19 patients, while decreasing among other patients.ConclusionsThe intrinsic virulence of COVID-19 appeared higher than influenza. In addition, several critical functions, such as immune response, coagulation, heart and respiratory function and metabolism were uniquely affected by COVID-19.

Anticoagulation Clinic Protocol and Electronic Medical Records in Patients Treated with Warfarin: Do They Increase the Likelihood of Achieving Therapeutic INR?

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 5090-5090
Author(s):  
Urmeel H Patel ◽  
Liya Galooshian ◽  
Franklin Fontem ◽  
Nadine Kalavazoff ◽  
Jordan Klein ◽  
...  
Keyword(s):  
Electronic Medical Records ◽  
Therapeutic Range ◽  
Medical Records ◽  
Warfarin Therapy ◽  
Conflicts Of Interest ◽  
Outpatient Setting ◽  
Anticoagulation Clinic ◽  
P Value ◽  
Protocol Implementation ◽  
Study Results

Abstract Introduction Managing patients on warfarin therapy is known to be a challenging task in the outpatient setting. One of the methods used to improve warfarin therapy in the outpatient setting and increase patient compliance and time in therapeutic range (TTR) has been to refer the patient to an anticoagulation clinic. Anticoagulation clinics are used to achieve a higher TTR by using a protocol to standardize the management of warfarin therapy. This study looks into whether the implementation of a protocol to manage warfarin therapy and electronic medical records (EMR) to record the management have any effect on the patients’ TTR. 

 Method A retrospective study was completed on patients being managed on warfarin therapy and were a part of an anticoagulation clinic. A chart review was done on ninety-one patients. All INR results were collected on the patients prior to and after the interventions were implemented and included their therapeutic range. The number of days until the INR became therapeutic and the dosage of warfarin required for patients to remain in the therapeutic range were also collected. Chi-square tests were done to analyze the data to determine whether the interventions improved patients’ TTR. Results Prior to EMR implementation 62.76% of tests were found to be within therapeutic range; after EMR implementation 58.96% of tests were found to be within therapeutic range with a p-value of 0.0604. Prior to the protocol implementation, 65.41% of tests were within therapeutic range compared to 59.75% of tests within therapeutic range after protocol implementation with a p-value of 0.0409. 

 Conclusion Our results showed EMR implementation did not have any effect on the TTR for patients on warfarin therapy. Furthermore, when a protocol was implemented to standardize warfarin therapy and management in the anticoagulation clinic setting, study results revealed the TTR decreased with the standardized protocol with a p-value found to be statistically significant. In conclusion, the data suggests the management of warfarin therapy should be done on an individual patient case-by-case basis rather than a standardized approach to increase TTR. Disclosures No relevant conflicts of interest to declare.

scholarly journals Improving postpartum hemorrhage risk prediction using longitudinal electronic medical records

2021 ◽  
Author(s):  
Amanda B Zheutlin ◽  
Luciana Vieira ◽  
Shilong Li ◽  
Zichen Wang ◽  
Emilio Schadt ◽  
...  
Keyword(s):  
Electronic Medical Records ◽  
Postpartum Hemorrhage ◽  
Medical Records ◽  
Assessment Tool ◽  
Vital Signs ◽  
Area Under The Curve ◽  
Test Sample ◽  
Feature Model ◽  
Gradient Boosting ◽  
Clinical Feature

ABSTRACTObjectivePostpartum hemorrhage (PPH) remains a leading cause of preventable maternal mortality in the US. Our goal was to develop a novel risk assessment tool and compare its accuracy to those used in current practice.Materials and MethodsWe used a PPH digital phenotype we developed and validated previously to identify 6,639 cases from our delivery cohort (N=70,948). Using a vast array of known and potential risk factors extracted from electronic medical records available prior to delivery, we trained a gradient boosting model in a subset of our cohort. In a held-out test sample, we compared performance of our model to three clinical risk tools and one previously published model.ResultsOur 24-feature model achieved an area under the curve (AUC) of 0.71 (95% confidence interval [CI], 0.69-0.72), higher than all other tools (research-based AUC: 0.67 [95%CI, 0.66-0.69], clinical AUCs: 0.55 [95%CI, 0.54-0.56] to 0.61 [95%CI, 0.59-0.62]). Five features were novel including red blood cell indices and infection markers measured standardly upon admission. Additionally, we identified inflection points for several vital signs and labs where risk rose substantially. Most notably, patients with median intrapartum systolic blood pressure above 132mmHg had an 11% [interquartile range, 4%] median increase in relative risk for PPH.ConclusionsWe developed a novel approach for predicting PPH and identified clinical feature thresholds that can guide intrapartum monitoring for PPH risk. Our results suggest our model is an excellent candidate for prospective evaluation and could ultimately reduce PPH morbidity and mortality through early detection and prevention.

scholarly journals 894 An Audit of Venous Thromboembolism Prophylaxis in A Busy ENT Department

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A Connelly ◽  
A Williamson
Keyword(s):  
Risk Assessment ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Low Molecular Weight ◽  
Thromboembolism Prophylaxis ◽  
Pharmacological Prophylaxis ◽  
Prescription Rates ◽  
Hospital Morbidity ◽  
Pro Forma ◽  
Appropriate Prescription

Abstract Aim Venous thromboembolisms (VTEs) are a common and preventable cause of in-hospital morbidity and mortality. Assessment of risk factors (RFs) on admission and appropriate prescription of mechanical (e.g., TEDS) and/or pharmacological prophylaxis (e.g., low-molecular-weight heparin (LMWH)) is crucial. This is especially true in ENT where the variety of patient cohorts make a one-size-fits-all approach unsatisfactory. Guidelines from ENT UK reflect this. Method Electronic medical records were retrospectively reviewed for all emergency and pre-operative admissions (n = 173) to an adult ENT ward over 8 weeks. Adherence to the ENT UK guideline was assessed. Results 58% of patients had VTE RFs, 27% had bleeding RFs, 2% had mechanical thromboprophylaxis contraindications. VTE risk assessment was clearly carried out for 39% of admissions. 63 patients (36%) met the criteria for LMWH prescription. 22 (35%) received it. 5 received LMWH without meeting the criteria. 96 patients (55%) met the criteria for TEDS prescription. 5 (5%) received it. 1 received TEDS without meeting the criteria. Overall, 45% of admissions had both prescribed according to the guideline. Using a pro-forma (n = 148) significantly improved risk assessment rates (43% vs. 12%), but not correct prescription rates (45% vs 40%) compared to freehand clerking (n = 25). No patients developed a VTE or unexpected bleeding. Conclusions Risk assessment and prescription of pharmacological and, especially, mechanical thromboprophylaxis for those who met the relevant criteria has significant room for improvement. However, no apparent harm occurred because of this. Further work will focus on developing a departmental policy and educating staff on its application.

scholarly journals Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Development of a Tool by Adapted Delphi Procedure (Preprint)

2019 ◽  
Author(s):  
Leandra Falck ◽  
Marco Zoller ◽  
Thomas Rosemann ◽  
Nahara Anani Martínez-González ◽  
Corinne Chmiel
Keyword(s):  
Primary Care ◽  
Chronic Diseases ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Chronic Conditions ◽  
Evidence Based ◽  
Term Care ◽  
Delphi Procedure ◽  
User Friendly

BACKGROUND Long-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists. OBJECTIVE The aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR. METHODS We used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators’ utility in practice and summarized them into a user-friendly layout. RESULTS This multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs. CONCLUSIONS Our generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.

Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information

2004 ◽  
Vol 43 (05) ◽  
pp. 537-542 ◽  
Author(s):  
R. Klar
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Patient Information ◽  
Medical Records ◽  
Data Set ◽  
The 1960S ◽  
User Friendly ◽  
Support Evaluation

Summary Objectives: To present an overview of early European and American work on Electronic Medical Records and patient information. Method: The invited lectures of “pioneers of electronic patient information” given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed. Results: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first com-puterized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency. Conclusions: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

Sign in / Sign up

Export Citation Format

Share Document