Electronic Records Remediation Project

BackgroundAbuse of older people in care homes is an on-going problem. GPs, as the most frequent practitioner group visiting care homes, have an important role in detecting and reporting abuse. However, there is little research about GPs’ experiences of working in care homes and how they work to safeguard residents.AimTo explore the challenges experienced by GPs working in this unique environment and how these impact on safeguarding.MethodAn online survey collected qualitative data about GPs’ experiences as visiting professionals to care homes, with an emphasis on safeguarding. A thematic analysis identified key themes.ResultsIn total, 58 completed surveys were returned, with a range of practitioner experience represented (1–30 years). Approximately 70% were GP partners, with the remainder salaried and locum doctors. Over one third reported they had witnessed signs of definite or possible abuse within care homes. Emerging themes related to the complex care home context, in which residents had multiple health needs and GPs had to build multiple relationships with managers, carers, families, and residents. Difficulties in accessing information were reported; residents could not always provide information, GPs had to rely on others for information, and rarely had access to electronic records.ConclusionGP work in care homes is a complex and skilled role, in which GPs encounter evidence of poor care and abuse. Key themes in respect of barriers and facilitators of good care were highlighted. The reliance on others for information and the need to build relationships with staff/managers may raise tensions in respect of safeguarding practice.

Download Full-text

Models for Action: Practical Approaches to Electronic Records Management and Preservation.

10.21236/ada362862 ◽

1998 ◽

Cited By ~ 1

Author(s):

Kristine L. Kelly ◽

Alan Kowlowitz ◽

Theresa A. Pardo ◽

Darryl E. Green

Keyword(s):

Electronic Records ◽

Records Management ◽

Electronic Records Management

Download Full-text

Development of function-based classification model for electronic records

International Journal of Information Management ◽

10.1016/j.ijinfomgt.2016.04.009 ◽

2016 ◽

Vol 36 (4) ◽

pp. 626-634 ◽

Cited By ~ 2

Author(s):

Umi Asma’ Mokhtar ◽

Zawiyah M. Yusof ◽

Kamsuriah Ahmad ◽

Dian Indrayani Jambari

Keyword(s):

Classification Model ◽

Electronic Records

Download Full-text

179 Improving Operative Notes in Upper GI Surgery: An Innovative QI Project Utilising Existing Electronic Hospital Systems

British Journal of Surgery ◽

10.1093/bjs/znab134.379 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

H Sadik ◽

A Butt ◽

Z Gowie ◽

J Carew ◽

A Mehta ◽

...

Keyword(s):

Electronic Records ◽

Additional Information ◽

Operative Care ◽

Adequate Care ◽

Hospital Systems ◽

Operative Notes ◽

Mean Compliance ◽

Valuable Role ◽

Electronic Hospital

Abstract Introduction Operative notes play a valuable role in ensuring that surgical patients receive consistent and adequate care. There are many inherent difficulties affecting their quality. We performed a QI project to improve surgical operative notes at our centre. Method A questionnaire assessing subjective quality of operative notes was sent to all foundation doctors delivering post-operative care. Compliance to each inclusion recommendation in the RCS guidelines was analysed. A standardised template for operative notes was incorporated into the hospital’s electronic records system, compliance was then reassessed. Results Questionnaire responses (16) were better for typed vs hand-written notes in all domains: ease of accessing notes, following intra-operative steps, following post-operative plans and frequency of asking for additional information regarding plans. After implementation of the template, mean compliance across 19 RCS parameters improved from 69% (55 operations) to 89% (46 operations). Number of parameters with 100% compliance improved from 2/19 to 8/19. Compliance increased in 14/19 parameters, there was no change in 2/19 (already 100%) and a reduction was seen in 3/19. Conclusions Results from our analysis and questionnaire showed that typed notes were favourable when compared to hand-written. The introduction of a standardised electronic template, without investment in new software, improved compliance to RCS guidelines.

Download Full-text

The impact of COVID-19 related national lockdown on ophthalmic emergency in Italy: A multicenter study

European Journal of Ophthalmology ◽

10.1177/11206721211028046 ◽

2021 ◽

pp. 112067212110280

Author(s):

Maria L Salvetat ◽

Carlo Salati ◽

Patrizia Busatto ◽

Marco Zeppieri

Keyword(s):

Gender Bias ◽

Tertiary Care ◽

Lower Number ◽

Electronic Records ◽

Chi Square ◽

Efficient Access ◽

Chi Square Test ◽

Unpaired Student ◽

The Impact ◽

Wet Amd

Purpose: To assess ocular pathologies admitted to Italian Emergency Eye Departments (EEDs) during the COVID-19 pandemic national lockdown in 2020 in comparison with the same period in 2019. Methods: Electronic records of all patients presenting at EEDs of two tertiary-care Eye Centers during the COVID-19 national lockdown in Italy (March 10–May 3, 2020) were compared with the equivalent period in 2019. Main outcomes were patient age, gender, and diagnoses. Statistical analysis included unpaired Student t-tests, Poisson regression, and chi-square test. Results: Overall EED visits significantly decreased by 54.1% during the 2020 lockdown compared to 2019 (851 vs 1854, p < 0.001). During lockdown, patients showed comparable mean age (52.8 years in 2020 vs 53.3 years in 2019, p = 0.52) and significant male gender bias (61.1% in 2020 vs 55.8% in 2019, p < 0.0001). The most frequent pathologies were eye inflammations, trauma-related incidents, and spontaneous acute vitreous detachment. Patients with inflammation, headache/hemicrania, and spontaneous subconjunctival hemorrhages were significantly less, whereas those with trauma-related diagnoses were significantly higher during the lockdown as compared with 2019 ( p < 0.05). The proportion of non-urgent visits decreased from 17% in 2019 to 8% in 2020 ( p < 0.001). Conclusions: During the 2020 lockdown, there was a significant reduction of accesses to EED, especially for non-urgent pathologies. Potentially visual function threatening conditions, such as trauma-related pathologies, retinal detachment or ruptures, and wet AMD, showed lower number of cases but higher or stable proportion relative to the total caseload, suggesting a correct and efficient access to ophthalmic health care during the pandemic period.

Download Full-text

Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0040-1718869 ◽

2021 ◽

Vol 47 (01) ◽

pp. 074-083

Author(s):

Kathryn W. Chang ◽

Steve Owen ◽

Michaela Gaspar ◽

Mike Laffan ◽

Deepa R. J. Arachchillage

Keyword(s):

Fresh Frozen Plasma ◽

Electronic Records ◽

Blood Products ◽

Major Hemorrhage ◽

Fresh Frozen ◽

Dilutional Coagulopathy ◽

Baseline Characteristics ◽

The Impact ◽

Frozen Plasma ◽

Baseline Hemoglobin

AbstractThis study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5–11.75]) versus nonactivated (9 [6–12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.

Download Full-text