scholarly journals Validation and Quality Assessment of the Kilimanjaro Cancer Registry

2016 ◽  
Vol 2 (6) ◽  
pp. 381-386 ◽  
Author(s):  
Leah L. Zullig ◽  
Kristin Schroeder ◽  
Pilli Nyindo ◽  
Theresia Namwai ◽  
Elvis Silayo ◽  
...  
Keyword(s):  
Data Quality ◽  
Medical Record ◽  
Cancer Registry ◽  
Medical Records ◽  
Medical Center ◽  
Cancer Site ◽  
Cancer Information ◽  
Middle Income ◽  
Data Elements ◽  
High Level

Purpose Global cancer burden has increasingly shifted to low- and middle-income countries and is particularly pronounced in Africa. There remains a lack of comprehensive cancer information as a result of limited cancer registry development. In Moshi, Tanzania, a regional cancer registry exists at Kilimanjaro Christian Medical Center. Data quality is unknown. Our objective was to evaluate the completeness and quality of the Kilimanjaro Cancer Registry (KCR). Methods In October 2015, we conducted a retrospective review of KCR by validating the internal consistency of registry records with medical and pathology records. We randomly sampled approximately 100 total registry cases. Four reviewers not associated with the KCR manually collected data elements from medical records and compared them with KCR data. Results All 100 reviewed registry cases had complete cancer site and morphology included in the registry. Six had a recorded stage. For the majority (n = 92), the basis of diagnosis was pathology. Pathology reports were found in the medical record for 40% of patients; for the remainder, these were stored separately in the pathology department. Of sampled registry cases, the KCR and medical records were 98% and 94% concordant for primary cancer site and morphology, respectively. For 28%, recorded diagnosis dates were within 14 days of what was found in the medical record, and for 32%, they were within 30 days. Conclusion The KCR has a high level of concordance for classification and coding when data are retrieved for validation. This parameter is one of the most important for measuring data quality in a regional cancer registry.

scholarly journals Validation and quality assessment of the Kilimanjaro Cancer Registry.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 266-266
Author(s):  
Leah L. Zullig ◽  
Charles Muiruri ◽  
Pili Nyindo ◽  
Theresia Namwai ◽  
Francis Karia ◽  
...  
Keyword(s):  
Medical Record ◽  
Cancer Registry ◽  
Medical Center ◽  
Resource Planning ◽  
Cancer Registries ◽  
Cancer Site ◽  
High Quality Research ◽  
Middle Income ◽  
Diagnosis Date

266 Background: The global cancer burden has increasingly shifted to low and middle-income countries and is particularly pronounced in Africa. However, there remains a lack of comprehensive information about cancer incidence due to limited development of cancer registries. In Moshi, Tanzania, a regional cancer registry exists at Kilimanjaro Christian Medical Center (KCR). The quality of the registry data is unknown. Our objective was to evaluate the completeness and quality of the KCR. Methods: In October 2015 we conducted a retrospective review, validating internal consistency of registry records compared with paper-based medical and pathology records. We randomly sampled approximately 3% of over 3000 registry cases (n = 100), focused on cases abstracted from 2014-15. Four independent reviewers not associated with the KCR manually collected and compared key data elements (e.g., cancer site, morphology, diagnosis date). Data were collected using Microsoft Excel. Data management and analysis were conducted in Stata. Results: The KCR contains information on over 3000 patients from 32 tribal groups and 8 geographic areas in the Kilimanjaro region. All of the 100 reviewed cases had complete cancer site and morphology in the registry. Six had a recorded stage. For the majority of cases (n = 92) the basis of diagnosis was pathology. Pathology records were found in the medical record for 41% of cases; for the remainder, pathology records were stored separately in the pathology department. Of sampled cases, the KCR and medical records were 98% and 94% concordant for primary cancer site and morphology, respectively. For 28% of cases, recorded diagnosis dates were within 14 days of what was found in the medical record, and for 32% of cases they were within 30 days. Conclusions: Although training is needed to standardize diagnosis date definitions, this study suggests that KCR data is high quality. Research is needed to determine effectiveness at ascertaining all patients in its catchment area. The registry may have utility for resource planning and research purposes.

Comparison of Prescription and Medical Records in Reflecting Patient Antihypertensive Drug Therapy

1994 ◽  
Vol 28 (1) ◽  
pp. 99-104 ◽  
Author(s):  
Dale B. Christensen ◽  
Barbara Williams ◽  
Harold I. Goldberg ◽  
Diane P. Martin ◽  
Ruth Engelberg ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Health Maintenance Organizations ◽  
Antihypertensive Drug Therapy ◽  
Antihypertensive Medications ◽  
Pharmacy Records ◽  
Health Maintenance ◽  
Computer Based ◽  
High Level ◽  
Level Of Agreement

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

scholarly journals QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

2017 ◽  
Vol 1 (4) ◽  
pp. 98-99
Author(s):  
Zahra Mazloum khorasani ◽  
Mahmood Tara ◽  
Kobra Etminani ◽  
Zohre Moosavi ◽  
Zahra Ebnehoseini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Qualitative Evaluation ◽  
Cross Sectional Study ◽  
Diabetic Patients ◽  
Cross Sectional ◽  
Accurate Treatment ◽  
Diabetes Center ◽  
Data Elements ◽  
Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients.  Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

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.

A Comparison of Two Sources of Data on Fungaemia in Two Hospitals

2005 ◽  
Vol 34 (3) ◽  
pp. 88-93 ◽  
Author(s):  
Quoc Nguyen ◽  
Beth Reid
Keyword(s):  
Medical Record ◽  
Bloodstream Infection ◽  
Hospital Discharge ◽  
Medical Records ◽  
Hospital Environment ◽  
Hospital Discharge Data ◽  
Discharge Data ◽  
High Level

Fungal bloodstream infection (BSI) is of increasing concern in the hospital environment. This study compared routine hospital discharge data at two inner Sydney hospitals with a pathology database over a 6-year period. A high level of underreporting was found, with only 42% of the pathology database cases assigned an appropriate code in the hospital discharge data despite evidence of the infection being found in 97% of the medical records identified from the pathology database. The location of the evidence in the medical record had an impact on whether or not the infection was assigned a code. There was a greater likelihood that a code would be assigned if the infection was documented on the front sheet of the medical record. Improvements can be made to the reporting of fungal BSI if clinicians record it on the front sheet and if coders review the whole medical record before coding.

scholarly journals Essential Data Elements for Electronic Cardiovascular Medical Record Systems in Iran

2021 ◽  
Vol 10 (1) ◽  
pp. 54
Author(s):  
Abbas Sheikhtaheri ◽  
Farid Khorami ◽  
Hedyeh Mohammadzadeh
Keyword(s):  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Clinical Signs ◽  
Minimum Data Set ◽  
Nursing Interventions ◽  
Data Set ◽  
Minimum Data ◽  
Physical Examinations ◽  
Data Elements

Introduction: Electronic medical records play an important role in the management of patients. In order to develop cardiovascular electronic medical record systems, determining minimum data set is necessary. This study aimed to determine the essential data elements for electronic cardiovascular medical record systems.Methods: Medical records of patients with cardiovascular diseases and also the literature were reviewed to develop a questionnaire regarding the data elements.  87 cardiovascular specialists and residents as well as 50 nurses working in cardiovascular departments of hospitals affiliated with Iran University of Medical Sciences participated in the study. The data elements with at least 75% of agreement were considered essential for electronic medical records. Data were analyzed using descriptive statistics in SPSS software.Results: The essential  data elements were classified in 29 classes including admission, death, patients’ main complaints, clinical signs, observations, medications, cardiac surgery, risk factors, laboratory and pathology results, consultation, resuscitation, anesthetic, electrocardiography, blood transfusion or blood products, rehabilitation measures, angiography/venography, exercise testing, endoscopy/colonoscopy, medical imaging, echocardiography, nursing interventions, allergies and side effects, therapeutic implantations, cardiac examinations, physical examinations, angina, referrals, social backgrounds and history., Totally, out of 276 data elements, 245 elements were identified as the essential data elements for electronic cardiovascular medical record systems.Conclusion: In this study, essential data elements were defined for electronic cardiovascular medical records. Identifying cardiovascular minimum data set will be an effective step towards integrating and improving the management of these patients' information.

scholarly journals Description Of Medical Record Staff Based On Method Workload Indicator Staff Need In Kuningan Medical Center Hospital

2019 ◽  
Vol 6 (2) ◽  
pp. 42-50
Author(s):  
Rina Eka Aulia ◽  
M.H. Asiana Gabril ◽  
Riantina Luxiarti
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Survey Research ◽  
Medical Records ◽  
Research Method ◽  
Medical Center ◽  
Future Research ◽  
Health Work ◽  
Center Hospital ◽  
Descriptive Survey

Workload Indicator Staff Need (WISN) is a method of calculating the needs of real health human resources implemented in each health work unit. The purpose of this study is to describe the needs of Medical Record staff based on the WISN methodIn Kuningan Medical Center (KMC) Hospital. This research method is a descriptive survey research method, the population of this study is 8 medical records officers, and the sample is 8 patients and the sampling uses total sampling. The results were obtained from the WISN ratio of 10 people, namely: 3 outpatient registrations, 1 inpatient registration, 1 outpatient coding, 1 inpatient coding, 2 assembling people, and 2 filing people, so it can be concluded that there are advantages to outpatient registration and any shortages for assembling and filing. The suggestion of this research is that future research can use other methods.

scholarly journals Cancer Incidence in 12 Major Hospitals of Nepal

2018 ◽  
Vol 4 (Supplement 2) ◽  
pp. 126s-126s
Author(s):  
K.K. Pradhananga
Keyword(s):  
Medical Record ◽  
Cancer Registry ◽  
Cancer Incidence ◽  
Population Based ◽  
Cervix Uteri ◽  
Cancer Site ◽  
Cancer Data ◽  
Program Policy ◽  
Cancer Of The Cervix ◽  
Record Section

Background and context: In Nepal, no population based cancer registry program exists to know the incidence, prevalence, morbidity and mortality of cancer. Since 2003 AD we have been conducting hospital based cancer registry program in 7 major hospitals and now we include 12 hospitals in 2014 in the initiation of BP Koirala Memorial Cancer Hospital. Aim: To find out about the burden across a greater proportion of cancer from 12 major hospitals of Nepal. Strategy/Tactics: Coordination with 12 hospitals´ medical record section to abstract the cancer data. The cases were verified by name, age, sex, address, topography and morphology. Repeated cancer cases were excluded from database. Program/Policy process: The total 9036 cancer cases were included in this study to know the cancer incidence in 12 major hospitals in 2014. This was descriptive type of study and all cases were collected from medical record section for data analysis. Outcomes: Among case the mean age of the patients was 53.6 years. The common form of cancer for both sex was bronchus and lung (13.7%) followed by cervix uteri (9.4%) and breast (9.4%). Cancer of the cervix (17.0%) was the top ranking cancer site for female followed by breast (16.4%) and bronchus and lung (10.9%). Similarly, cancer of the bronchus and lung (17.2%) was the commonest cancer for male followed by stomach (7.6%) and larynx (6.2%). Female cases (54.0%) were frequently high than in male (46.0%). What was learned: This type of study shows burden across a greater proportion of cancer from 12 major hospitals, but the coverage may not represent the whole country.

scholarly journals Improving Population-Wide Collection of Stage at Diagnosis for Childhood Cancer: International Collaboration and Progress

2018 ◽  
Vol 4 (Supplement 2) ◽  
pp. 67s-67s
Author(s):  
J.F. Aitken ◽  
D.R. Youlden ◽  
L.J. O'Neill ◽  
K.R. Ballantine ◽  
S. Cross ◽  
...  
Keyword(s):  
Childhood Cancer ◽  
Medical Record ◽  
Cancer Registry ◽  
Cancer Survival ◽  
Cancer Registries ◽  
International Agency ◽  
Practical Implementation ◽  
Stage At Diagnosis ◽  
Computer Algorithms ◽  
Middle Income

Background: There are huge international disparities in childhood cancer survival. The International Agency for Research on Cancer's Global Initiative for Cancer Registry Development has improved cancer registry coverage of the world's population, particularly in low- and middle-income countries (LMICs). However, for virtually all registries around the world, the challenge remains of collecting comparable and population-wide information on stage at diagnosis. This information is essential to understand and address disparities in outcomes. In response to this, a UICC-endorsed set of consensus guidelines for assigning stage for 16 of the most common types of childhood cancer was recently developed (the Toronto Guidelines), for use by population registries in both high and LMICs. Aim: To trial the Toronto Guidelines on a population-basis, and develop a structured protocol, suitable for global implementation, for collecting the required data elements and assigning cancer stage at diagnosis for childhood cancer. Methods: Using an innovative approach, data items as defined in the Toronto Guidelines were gathered from the medical record and entered electronically. Stage at diagnosis was assigned automatically using computer algorithms, thus reducing errors and maximizing consistency. Data collection and assignment of stage were incorporated into an online platform that was then trialed in the national childhood cancer registries of Australia and New Zealand for cases diagnosed between 2006 and 2014. Results: Stage at diagnosis was successfully assigned for 94% of all eligible patients (n=1662) across both countries. In contrast, stage as recorded by the treating clinician was located in the medical record for only 39% of cases in Australia. Conclusion: Practical implementation of the Toronto Guidelines has been highly successful to date and further testing is planned in LMICs. This approach has the potential to improve global epidemiologic monitoring of childhood cancer and lead to better understanding of the reasons underlying disparities in outcome.

Methods and Implementation  of a Hospital-Based Cancer Registry in a Major City in a Low-to Middle-Income Country: The Case of Cali, Colombia

2021 ◽  
Author(s):  
Luis Gabriel Parra Lara ◽  
Diana M Mendoza-Urbano ◽  
Ángela R Zambrano ◽  
Andrea Valencia-Orozco ◽  
Juan C Bravo-Ocaña ◽  
...  
Keyword(s):  
Cancer Registry ◽  
Medical Center ◽  
Academic Medical Center ◽  
International Agency ◽  
Middle Income ◽  
Non Profit ◽  
Computing Platform ◽  
Data Collection Strategy ◽  
Academic Medical ◽  
Definition Of

Abstract Purpose To describe our experience upon developing and implementing a hospital-based cancer registry (HBCR) in a quaternary-level of care private non-profit academic medical center in Cali, Colombia. Methods HBCRs capture, in a given institution, every single patient with a confirmed malignancy. In this study, all cases evaluated between 2014 and 2018 were included in the HBCR. In compliance with the International Agency for Research on Cancer (IARC) recommendations, cases were classified as analytic or non-analytic. Data derived from an exhaustive selection of patients was stored in a computing platform owned by the institution, meeting the 2016 Facility Oncology Registry Data Standards (FORDS) recommendations. Quality control was performed by evaluating comparability, timeliness, validity, and completeness. Results A total of 24,405 new cases were registered between 2014 and 2018, from which 4,253 (17.4%) died. Among all cases, based on the anatomic location, most common malignancies were breast (n = 1,554), thyroid (n = 1,346), hematolymphoid (n = 1,251), prostatic (n = 805), and colorectal (n = 624). The behavior of the incidence was consistent with an incremental trend. Conclusion Upon implementing the HBCR, major challenges were identified (i.e. a precise definition of cases, the development of processes for capturing new cases, a standardized data collection strategy, and carrying-out an appropriate patient follow-up). Based on our experience, the success of an HBCR largely relies on the interest from the institution, the engagement of stakeholders and financial support, that is, it depends on the adequate access over time to funding, technological, and staffing resources.

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