scholarly journals In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study

2017 ◽  
Vol 17 (1) ◽  
Author(s):  
Judith M. Poldervaart ◽  
Marije A. van Melle ◽  
Sanne Willemse ◽  
Niek J. de Wit ◽  
Dorien L.M. Zwart
Keyword(s):  
Primary Care ◽  
Medical Record ◽  
Care Provider ◽  
Primary Care Provider ◽  
Medical Records ◽  
Medical Record Review ◽  
Review Study ◽  
Record Review ◽  
Prescription Changes

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.

Patterns and prognostic indicators of response to CML treatment in a multi-country medical record review study

2012 ◽  
Vol 95 (5) ◽  
pp. 535-544 ◽  
Author(s):  
Peter C. Trask ◽  
Debanjali Mitra ◽  
Shrividya Iyer ◽  
Sean D. Candrilli ◽  
James A. Kaye
Keyword(s):  
Medical Record ◽  
Medical Record Review ◽  
Prognostic Indicators ◽  
Review Study ◽  
Record Review

scholarly journals Design of a medical record review study on the incidence and preventability of adverse events requiring a higher level of care in Belgian hospitals

2012 ◽  
Vol 5 (1) ◽  
Author(s):  
Annemie Vlayen ◽  
Kristel Marquet ◽  
Ward Schrooten ◽  
Arthur Vleugels ◽  
Johan Hellings ◽  
...  
Keyword(s):  
Adverse Events ◽  
Medical Record ◽  
Medical Record Review ◽  
Level Of Care ◽  
Review Study ◽  
Record Review

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]

scholarly journals The effect of a Housing First intervention on primary care retention among homeless individuals with mental illness

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0246859
Author(s):  
Adam Whisler ◽  
Naheed Dosani ◽  
Matthew J. To ◽  
Kristen O’Brien ◽  
Samantha Young ◽  
...  
Keyword(s):  
Primary Care ◽  
Mental Illness ◽  
Care Provider ◽  
Primary Care Provider ◽  
Medical Records ◽  
Primary Care Providers ◽  
Retention Rates ◽  
Housing First ◽  
Care Providers ◽  
Treatment As Usual

Background Primary care retention, defined as ongoing periodic contact with a consistent primary care provider, is beneficial for people with serious chronic illnesses. This study examined the effect of a Housing First intervention on primary care retention among homeless individuals with mental illness. Methods Two hundred individuals enrolled in the Toronto site of the At Home Project and randomized to Housing First or Treatment As Usual were studied. Medical records were reviewed to determine if participants were retained in primary care, defined as having at least one visit with the same primary care provider in each of two consecutive six-month periods during the 12 month period preceding and following randomization. Results Medical records were obtained for 47 individuals randomized to Housing First and 40 individuals randomized to Treatment As Usual. During the one year period following randomization, the proportion of Housing First and Treatment As Usual participants retained in primary care was not significantly different (38.3% vs. 47.5%, p = 0.39). The change in primary care retention rates from the year preceding randomization to the year following randomization was +10.6% in the Housing First group and -5.0% in the Treatment As Usual group. Conclusion Among homeless individuals with mental illness, Housing First did not significantly affect primary care retention over the follow-up period. These findings suggest Housing First interventions may need to place greater emphasis on connecting clients with primary care providers.

We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record

2015 ◽  
Vol 10 (5) ◽  
pp. 307-310 ◽  
Author(s):  
Leslie Sheu ◽  
Kelly Fung ◽  
Michelle Mourad ◽  
Sumant Ranji ◽  
Ethel Wu
Keyword(s):  
Primary Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Care Provider ◽  
Primary Care Provider ◽  
Provider Communication
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