scholarly journals Documentation of Dual Sensory Impairment in Electronic Medical Records

2014 ◽  
Vol 56 (2) ◽  
pp. 313-317 ◽  
Author(s):  
Brittney Dullard ◽  
Gabrielle H. Saunders
Keyword(s):  
Hearing Loss ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Vision Loss ◽  
Clinical Care ◽  
Primary Care Providers ◽  
Sensory Impairment ◽  
Care Providers ◽  
Sensory Impairments ◽  
Dual Sensory Impairment

Abstract Purpose of the Study: To examine the documentation of sensory impairment in the electronic medical records (EMRs) of Veterans with both hearing and vision losses (dual sensory impairment [DSI]). Design and Methods: A retrospective chart review of the EMRs of 20 patients with DSI was conducted. Providers’ documentation of the presence of sensory impairment, the use of assistive technology during clinical appointments, and the content of notes mentioning communication issues were extracted from each chart note in the EMR for the prior 6 years. Results: Primary care providers documented DSI in 50% of EMRs, vision loss alone in 40%, and hearing loss alone in 10% of EMRs. Audiologists documented vision loss in 50% of cases, whereas ophthalmologists/optometrists documented hearing loss in 15% of cases. Examination of two selected cases illustrates that care can be compromised when providers do not take note of sensory impairments during planning and provision of clinical care. Implications: Sensory impairment is poorly documented by most providers in EMRs. This is alarming because vision and hearing affect patient–physician communication and the use of medical interventions. The results of this study raise awareness about the need to document the presence of sensory impairments and use the information when planning treatment for individuals with DSI.

scholarly journals Body mass index and waist circumference documentation in Canadian primary care electronic medical records

2020 ◽  
Author(s):  
Cliff Lindeman ◽  
Allyson Jones ◽  
Michael Cummings ◽  
Anh N. Q. Pham ◽  
PhD Carla RD ◽  
...  
Keyword(s):  
Primary Care ◽  
Body Mass Index ◽  
Waist Circumference ◽  
Electronic Medical Records ◽  
Body Mass ◽  
Medical Records ◽  
Primary Care Providers ◽  
Research Database ◽  
Care Providers ◽  
Surveillance Network

Abstract Background: Electronic medical records (EMR) are commonly used in primary care to document patient measurements including height and weight that are then used to produce body mass index (BMI) scores. However, little is known about the proportion of waist circumference (WC) documentation compared to BMI and the characteristics of patients with these measures. This study used a pan-Canadian research database, sourced from primary care EMRs, to describe BMI and WC documentation in primary care. Methods: A retrospective cohort design of primary care providers participating in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), this study presented descriptive, observational findings of EMR inputs. Frequencies and percentages of median BMI and WC documentation in CPCSSN EMRs and patient demographic characteristics are compared. Results: Of 707,819 Canadian patients aged of 40 or older, at least one BMI input was recorded for 58.6% and 11.5% had WC notations. The majority of patients (98.1%) with at least one WC measurement also had a BMI measurement while conversely 19.2% of patients with at least one BMI measurement also had a WC measurement. The most common median BMI category was overweight (36.9%) and median WC was 95.0 centimetres (IQR = 21.5).Conclusions: This study reports the documentation of obesity and overweight in select Canadian primary care EMRs infrequently recorded WC when compared to BMI. Future studies should examine the frequency and categories of anthropometric measurements in people with commonly managed chronic conditions and whether BMI and WC inputs are missing at random. Trial registration: Not applicable for this study.

Accommodating Dual Sensory Loss in Everyday Practice

2014 ◽  
Vol 19 (1) ◽  
pp. 4-16
Author(s):  
Katharina V. Echt ◽  
Gabrielle H. Saunders
Keyword(s):  
Health Care ◽  
Hearing Loss ◽  
Older People ◽  
Vision Loss ◽  
Sensory Loss ◽  
Sensory Impairment ◽  
Health Care Settings ◽  
Speech Language Pathologist ◽  
Dual Sensory Loss ◽  
Dual Sensory Impairment

Dual sensory impairment is increasingly prevalent in people over age 65. The combination of vision loss and hearing loss impacts not only day-to-day function from the perspective of the patient, but must also be considered by the speech-language pathologist working with older people in health care settings. This article will discuss the implications of dual sensory impairment for both patients and professionals, and will provide strategies to support communication.

scholarly journals 530 An Audit of Appropriate Documentation Following Urethral Catheterisation

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
I Dokubo ◽  
J Armitage
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Clinical Care ◽  
Medical Personnel ◽  
Urethral Catheter ◽  
Residual Volume ◽  
Urethral Catheterisation ◽  
Catheter Size ◽  
Medical Records System ◽  
Insertion Process

Abstract Introduction Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation is necessary to ensure safe clinical care and to reduce the risk of litigation. Method We randomly reviewed electronic notes of patients seen by the on-call urology team who had a urethral catheter inserted in September 2020. Reviewing the trust’s guidelines, we considered that appropriate documentation should include reference to the following 10 items; indication, chaperone present, consent obtained, groin examination, catheter size, catheter type, insertion process, urine colour, water in balloon and residual volume were reviewed. Results A total of 50 patients were included. 72%(36/50) were inserted by a member of the urology team. Only 28%(14/50) had all 10 items documented. Indication for catheterisation was best documented at 94%(47/50) while presence of a chaperone and groin examination (i.e. presence of a foreskin and its replacement post-catheterisation) were the lowest at 44%(22/50). Conclusions This study shows there is low compliance to adequate documentation of urethral catheterisation. A ‘smart phrase’ has been developed for use with our Trusts electronic medical records system to assist clinicians with appropriate documentation. Clinicians that use the phrase ‘.icat’ are prompted to document all 10 requisite items. This uses the mnemonic i-CATHETAR [indication, Chaperone and consent, groin Assessment, Tube (catheter size and type), insertion process (Hard/Easy), urine Tint, Aqua in balloon, Residual volume]. A second audit cycle is currently being done to review the effectiveness of this intervention.

Psychological, Social and Technical Factors Influencing Electronic Medical Records Systems Adoption by U.S. Physicians: A Systematic Model

2020 ◽  
Author(s):  
Raghid El-Yafouri ◽  
Leslie Klieb ◽  
Valérie Sabatier
Keyword(s):  
United States ◽  
Health Care ◽  
Medical Care ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Service Providers ◽  
Financial Burden ◽  
The United States ◽  
Care Providers ◽  
Intention To Adopt

Abstract Background: Wide adoption of electronic medical records (EMR) systems in the United States can lead to better quality medical care at a lower cost. Despite the laws and financial subsidies by the U.S. government for service providers and suppliers, the adoption has been slow. Understanding the EMR adoption drivers for physicians and the role of policymaking can translate into increased adoption rate and enhanced information sharing between medical care providers. Methods: Physicians across the United States were surveyed to gather primary data on their psychological, social, and technical perceptions toward EMR systems. This quantitative study builds on the Theory of Planned Behavior, the Technology Acceptance Model, and the Diffusion of Innovation theory to propose, test, and validate an innovation adoption model for the health care industry. 382 responses were collected and data were analyzed via linear regression to uncover the effects of 12 variables on the intention to adopt EMR systems.Results: Regression model testing uncovers that government policymaking or mandates and other social factors have little or negligible effect on physicians’ intention to adopt an innovation. Rather, physicians are directly driven by their attitudes and ability to control, and indirectly motivated by their knowledge of the innovation, the financial ability to acquire the system, the holistic benefits to their industry, and the relative advancement of the system compared to others.Conclusions: A unidirectional mandate from the government is not sufficient for physicians to adopt an innovation. Government, health care associations, and EMR system vendors can benefit from our findings by working toward increasing the physicians’ knowledge of the proposed innovation, socializing how medical care providers and the overall industry can benefit from EMR system adoption, and solving for the financial burden of system implementation and sustainment.

scholarly journals Management of an ophthalmology department during COVID-19 pandemic in Milan, Italy

2020 ◽  
pp. 112067212096033 ◽  
Author(s):  
Emanuela Filomena Legrottaglie ◽  
Laura Balia ◽  
Fabrizio Ivo Camesasca ◽  
Jose Luis Vallejo-Garcia ◽  
Giovanni Fossati ◽  
...  
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Vision Loss ◽  
Healthcare Providers ◽  
Northern Italy ◽  
Containment Measures ◽  
Minor Surgery ◽  
Patients At Risk ◽  
Management Experience ◽  
Corneal Collagen

Purpose: Spreading from China, COVID-19 pandemic reached Italy, the first massively involved western nation. At the beginning of March, 2020 in Northern Italy a complete lockdown of activities was imposed. Access to all healthcare providers, was halted for patients with elective problems. We present the management experience of the Humanitas Clinical and Research Center Ophthalmology Department in Rozzano, Milan, Italy, during the lockdown. Methods: Containment measures were taken to reduce viral transmission and identify infected patients. All planned visits were canceled but for those not deferrable. Social distancing was introduced reducing number of visits per hour. Minor surgery for progressive pathologies was continued. As the lockdown prolonged, we reorganized patient care. All canceled cases were evaluated by electronic medical records analysis and telephonic triage, to identify, recall, and visit patients at risk of vision loss. Results: From March 9, to April 30, 2020 we performed a total of 930 visits and 612 exams. Some visits ( n = 698) and exams ( n = 160) were deemed as necessary for continuity of care and performed as planned. Among the remaining 1283 canceled appointments, after evaluation 144 visits and 32 instrumental exams were classified as urgent and rapidly rescheduled. Performed surgical activities were limited to corneal collagen cross linking ( n = 39) and intravitreal injections ( n = 91), compared to 34 and 94, respectively, in the same period of 2019. Conclusion: In-office activities deemed not deferrable were performed safely. The recall service was highly appreciated by all patients. No patient or staff member reported symptoms of COVID-19.

scholarly journals Dual sensory impairment: The association between glaucomatous vision loss and hearing impairment and function

PLoS ONE ◽  
2018 ◽  
Vol 13 (7) ◽  
pp. e0199889 ◽  
Author(s):  
Lucy I. Mudie ◽  
Varshini Varadaraj ◽  
Prateek Gajwani ◽  
Beatriz Munoz ◽  
Pradeep Ramulu ◽  
...  
Keyword(s):  
Hearing Impairment ◽  
Vision Loss ◽  
Sensory Impairment ◽  
And Function ◽  
Dual Sensory Impairment

scholarly journals 01 Adolescent and Young Adult Central Nervous System Tumour Survivors: Documentation of late-effects risks and screening recommendations in British Columbia, Canada

2018 ◽  
Vol 45 (S3) ◽  
pp. S1-S1
Author(s):  
A. Fuchsia Howard ◽  
Jordan Tran ◽  
Avril Ullett ◽  
Michael McKenzie ◽  
Karen Goddard
Keyword(s):  
Primary Care ◽  
Central Nervous System ◽  
Nervous System ◽  
Radiation Therapy ◽  
Young Adult ◽  
Late Effects ◽  
Medical Records ◽  
Primary Care Providers ◽  
Adolescent And Young Adult ◽  
Care Providers

Survivors of adolescent and young adult (AYA) central nervous system (CNS) neoplasms are at risk for late effects (LE) - treatment-related health problems occurring more than 5 years after therapy). Since, in Canada, AYA survivors are usually followed in the community, information must be conveyed to primary care providers to guide risk-based follow-up care. Objective: To assess documentation of LE risks and screening recommendations (SR) in medical records of AYA CNS tumor survivors treated with radiation therapy. Methods: The medical records of all patients diagnosed with a CNS neoplasm (benign or malignant) at ages 15-39 years, treated between 1985 and 2010 in the province of British Columbia, surviving >5 years and discharged to the community were assessed. Documentation of LE and SR were extracted, and analyzed descriptively. Results: Among 132 survivors (52% female), treated with radiation therapy (95% partial brain, 10% craniospinal, 8% partial spine, and 4% whole brain) and chemotherapy (17%), 19% of charts included no documentation of LE risks, 26% included only non-specific documentation, and 55% had minimal documentation (1 or 2 LE). Documentation of at least one specific LE increased from 24% in 1980-1989, to 54% in 1990-1999, to 86% in 2000 – 2010. Based on treatment information, all survivors were at high-risk for LE, such as radiation induced neoplasm, meningioma and cerebrovascular events. Yet, SR were documented in only 25% of charts. Conclusions: The documentation of LE risks and screening recommendations has been limited, highlighting the need to improve written communication with primary care providers.

Serious illness communication among patients with head and neck cancer.

2019 ◽  
Vol 37 (31_suppl) ◽  
pp. 2-2
Author(s):  
Floyd Buen ◽  
Emily J Martin ◽  
Neil Wenger ◽  
Kirsten Buen ◽  
Anne M. Walling
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
Retrospective Analysis ◽  
Neck Cancer ◽  
Medical Records ◽  
Primary Care Providers ◽  
Treatment Preferences ◽  
Care Providers ◽  
Goals Of Care ◽  
Serious Illness

2 Background: Head and neck cancer is associated with significant morbidity and mortality, yet little is known about the frequency and content of discussions addressing patients’ values, goals of care, and treatment preferences. Methods: Using an institutional cancer registry, we conducted a retrospective analysis of 70 decedents who underwent surgical treatment for squamous cell carcinoma of the head and neck. We abstracted patients’ medical records using a standardized template. An independent reviewer re-abstracted 20% of the records. For abstracted data pertaining to documented values, goals of care, and/or treatment preferences our inter-rater reliability was greater than 93%. Results: The mean age at diagnosis was 66 years and 69% were male. An enduring advance directive, a completed Physician Order for Life Sustaining Treatment form, and a serious illness conversation documented in the medical record were noted in 27%, 4%, and 49% of the medical records, respectively. Half of the documented goals of care discussions were held in the inpatient setting, over 50% were held in the last month of life, and 25% were held in the last week of life. These conversations involved specialist palliative care providers (47%), hematologist/oncologists (41%), hospitalists (32%), head and neck surgeons (21%), radiation oncologists (19%), and intensivists (18%). None of these discussions involved patients’ primary care providers. Of those with a known location of death, 58% died in the hospital and 4 out of 5 of these patients died during attempted cardiopulmonary resuscitation. Conclusions: In this retrospective analysis, serious illness communication was documented in the minority of patients who died of head and neck cancer. These discussions occurred late in the trajectory of illness. The continuity relationships of teams treating head and neck cancer patients (e.g., head and neck surgeon, radiation/oncologist and hematologist/oncologist) situate these clinicians in the best position to enact serious illness conversations. These data suggest that opportunities to have these discussions upstream are often missed.

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