scholarly journals Template Design and Analysis: Integrating Informatics Solutions to Improve Clinical Documentation

2020 ◽  
Author(s):  
Justin Iannello
Keyword(s):  
Clinical Documentation ◽  
Template Design

Structured Reporting of Medical Findings: Evaluation of a System in Gastroenterology

1992 ◽  
Vol 31 (04) ◽  
pp. 268-274 ◽  
Author(s):  
W. Gaus ◽  
J. G. Wechsler ◽  
P. Janowitz ◽  
J. Tudyka ◽  
W. Kratzer ◽  
...  
Keyword(s):  
Structured Data ◽  
Structured Reporting ◽  
Free Text ◽  
Clinical Documentation ◽  
Abdominal Sonography ◽  
Technical Examination ◽  
Medical Reports ◽  
Time Required ◽  
Upper Abdominal ◽  
Structured Approach

Abstract:A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Computer-Aided Diagnosis in Jaundice: Comparison of Knowledge-based and Probabilistic Approaches

1996 ◽  
Vol 35 (01) ◽  
pp. 41-51 ◽  
Author(s):  
F. Molino ◽  
D. Furia ◽  
F. Bar ◽  
S. Battista ◽  
N. Cappello ◽  
...  
Keyword(s):  
Clinical Presentation ◽  
Clinical Information ◽  
Diagnostic Value ◽  
Clinical Findings ◽  
Clinical Documentation ◽  
Data Set ◽  
Knowledge Based ◽  
Number Of Patients ◽  
Support Tools ◽  
Aided Diagnosis

AbstractThe study reported in this paper is aimed at evaluating the effectiveness of a knowledge-based expert system (ICTERUS) in diagnosing jaundiced patients, compared with a statistical system based on probabilistic concepts (TRIAL). The performances of both systems have been evaluated using the same set of data in the same number of patients. Both systems are spin-off products of the European project Euricterus, an EC-COMACBME Project designed to document the occurrence and diagnostic value of clinical findings in the clinical presentation of jaundice in Europe, and have been developed as decision-making tools for the identification of the cause of jaundice based only on clinical information and routine investigations. Two groups of jaundiced patients were studied, including 500 (retrospective sample) and 100 (prospective sample) subjects, respectively. All patients were independently submitted to both decision-support tools. The input of both systems was the data set agreed within the Euricterus Project. The performances of both systems were evaluated with respect to the reference diagnoses provided by experts on the basis of the full clinical documentation. Results indicate that both systems are clinically reliable, although the diagnostic prediction provided by the knowledge-based approach is slightly better.

scholarly journals Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Eric D. Moyer ◽  
Erik B. Lehman ◽  
Matthew D. Bolton ◽  
Jennifer Goldstein ◽  
Ariana R. Pichardo-Lowden
Keyword(s):  
Blood Glucose ◽  
Continuity Of Care ◽  
Clinical Documentation ◽  
Stress Hyperglycemia ◽  
Optimal Care ◽  
Continuity Clinic ◽  
Altered Glucose ◽  
Discharge Summaries

AbstractStress hyperglycemia (SH) is a manifestation of altered glucose metabolism in acutely ill patients which worsens outcomes and may represent a risk factor for diabetes. Continuity of care can assess this risk, which depends on quality of hospital clinical documentation. We aimed to determine the incidence of SH and documentation tendencies in hospital discharge summaries and continuity notes. We retrospectively examined diagnoses during a 12-months period. A 3-months representative sample of discharge summaries and continuity clinic notes underwent manual abstraction. Over 12-months, 495 admissions had ≥ 2 blood glucose measurements ≥ 10 mmol/L (180 mg/dL), which provided a SH incidence of 3.3%. Considering other glucose states suggestive of SH, records showing ≥ 4 blood glucose measurements ≥ 7.8 mmol/L (140 mg/dL) totaled 521 admissions. The entire 3-months subset of 124 records lacked the diagnosis SH documentation in discharge summaries. Only two (1.6%) records documented SH in the narrative of hospital summaries. Documentation or assessment of SH was absent in all ambulatory continuity notes. Lack of documentation of SH contributes to lack of follow-up after discharge, representing a disruptor of optimal care. Activities focused on improving quality of hospital documentation need to be integral to the education and competency of providers within accountable health systems.

scholarly journals Persistence of SARS-CoV-2 Viral RNA in Nasopharyngeal Swabs after Death: An Observational Study

2021 ◽  
Vol 9 (4) ◽  
pp. 800
Author(s):  
Francesca Servadei ◽  
Silvestro Mauriello ◽  
Manuel Scimeca ◽  
Bartolo Caggiano ◽  
Marco Ciotti ◽  
...  
Keyword(s):  
Viral Load ◽  
Observational Study ◽  
Real Time ◽  
Real Time Pcr ◽  
Pcr Detection ◽  
Viral Rna ◽  
Clinical Documentation ◽  
Post Mortem ◽  
Medical Assistance ◽  
Time Points

The aim of this study was to investigate the persistence of SARS-CoV-2 in post-mortem swabs of subjects who died from SARS-CoV-2 infection. The presence of the virus was evaluated post-mortem from airways of 27 SARS-CoV-2 positive patients at three different time points (T1 2 h; T2 12 h; T3 24 h) by real-time PCR. Detection of antibodies to SARS-CoV-2 was performed by Maglumi 2019-nCoV IgM/IgG chemiluminescence assay. SARS-CoV-2 viral RNA was still detectable in 70.3% of cases within 2 h after death and in 66,6% of cases up to 24 h after death. Our data showed an increase of the viral load in 78,6% of positive individuals 24 h post-mortem (T3) in comparison to that evaluated 2 h after death (T1). Noteworthy, we detected a positive T3 post-mortem swab (24 h after death) from 4 subjects who were negative at T1 (2 h after death). The results of our study may have an important value in the management of deceased subjects not only with a suspected or confirmed diagnosis of SARS-CoV-2, but also for unspecified causes and in the absence of clinical documentation or medical assistance.

Automating Clinical Documentation with Digital Scribes: Understanding the Impact on Physicians

2021 ◽  
Author(s):  
Brenna Li ◽  
Noah Crampton ◽  
Thomas Yeates ◽  
Yu Xia ◽  
Xirong Tian ◽  
...  
Keyword(s):  
Clinical Documentation ◽  
The Impact

scholarly journals 964 Telemedicine: Speedy Triage Tool or Clinical Record?

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A Ghareib ◽  
Z Vinnicombe ◽  
G Visser ◽  
A Ra ◽  
M Mantella ◽  
...  
Keyword(s):  
Plastic Surgery ◽  
Compliance Rate ◽  
Clinical Record ◽  
Portal System ◽  
Clinical Documentation ◽  
University Hospitals ◽  
Record Keeping ◽  
Clinical Document ◽  
National Guidance

Abstract Introduction St. George’s University Hospitals NHS Foundation Trust is a tertiary plastic surgery centre serving a population of 3.5 million in and around South West London. Telemedicine Referral Image Portal System (TRIPS) is integral to our service, allowing triage of patients in remote locations. During Covid, TRIPS helped in reducing footfall and streamlining out of hospital referrals to reduce unnecessary transfer. The aim of this project was to assess the quality of clinical documentation for emergency referrals to plastic surgery via TRIPS. Method We performed a retrospective review of all patients referred to plastic surgery via TRIPS during April 2020. Documentation standards were determined from national guidance. After introduction of a condensed guide, a second review was performed four months later. Results In April, 131 referrals were recorded on TRIPS. Only 22.9% of records met the standard. The most common omission was treatment advice. Following introduction of guidance, 215 TRIPS records were reviewed. The quality of clinical documentation improved in all aspects with a compliance rate of 89%. Conclusions Although TRIPS remains a useful tool for triage, it is a clinical document and must meet the standards of clinical record keeping. Introduction of clear guidelines improves overall compliance.

scholarly journals Clinical Documentation and Data Transfer from Ebola and Marburg Virus Disease Wards in Outbreak Settings: Health Care Workers’ Experiences and Preferences

Viruses ◽  
2014 ◽  
Vol 6 (2) ◽  
pp. 927-937 ◽  
Author(s):  
Silja Bühler ◽  
Paul Roddy ◽  
Ellen Nolte ◽  
Matthias Borchert
Keyword(s):  
Health Care ◽  
Health Care Workers ◽  
Data Transfer ◽  
Virus Disease ◽  
Marburg Virus ◽  
Clinical Documentation ◽  
Care Workers

Quality of Clinical Documentation and Anticoagulation Control in Patients With Chronic Nonvalvular Atrial Fibrillation in Routine Medical Care

2007 ◽  
Vol 22 (5) ◽  
pp. 327-333 ◽  
Author(s):  
Jack Ansell ◽  
J. Jaime Caro ◽  
Maribel Salas ◽  
Rowena J. Dolor ◽  
William Corbett ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Medical Care ◽  
Clinical Documentation ◽  
Nonvalvular Atrial Fibrillation ◽  
Routine Medical Care ◽  
Anticoagulation Control

Study and Development of CAPP Template Customization System

2011 ◽  
Vol 65 ◽  
pp. 1-4
Author(s):  
Zhi Ming Feng ◽  
Guo Fu Yin
Keyword(s):  
Process Planning ◽  
Template Model ◽  
Design Function ◽  
Template Design ◽  
Identical Type

This Document Proposes a System of Process Planning Template Design Based on XML. in this System, the Process Planning Documents Are Described by XML. the Author Analyzed the Process Card Template Model, and Devised a Template Design Function. Using this Function, Planners Are Able to Design and Modify Process Planning Cards According to their Requirements. the System Supplies a Uniform Interactive Platform for the Identical Type of Process Documents, and Lays a Strong Foundation for the Further Versatility and Practicability of a CAPP System.

scholarly journals 1358. Using natural language processing to optimize case ascertainment of acute otitis media in a large, state-wide pediatric practice network

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S690-S691
Author(s):  
Joshua C Herigon ◽  
Amir Kimia ◽  
Marvin Harper
Keyword(s):  
Natural Language Processing ◽  
Natural Language ◽  
Otitis Media ◽  
Language Processing ◽  
Validation Cohort ◽  
Recursive Partitioning ◽  
Acute Otitis Media ◽  
Clinical Documentation ◽  
Training Cohort ◽  
Icd Codes

Abstract Background Antibiotics are the most commonly prescribed drugs for children and frequently inappropriately prescribed. Outpatient antimicrobial stewardship interventions aim to reduce inappropriate antibiotic use. Previous work has relied on diagnosis coding for case identification which may be inaccurate. In this study, we sought to develop automated methods for analyzing note text to identify cases of acute otitis media (AOM) based on clinical documentation. Methods We conducted a cross-sectional retrospective chart review and sampled encounters from 7/1/2018 – 6/30/2019 for patients < 5 years old presenting for a problem-focused visit. Complete note text and limited structured data were extracted for 12 randomly selected weekdays (one from each month during the study period). An additional weekday was randomly selected for validation. The primary outcome was correctly identifying encounters where AOM was present. Human review was considered the “gold standard” and was compared to ICD codes, a natural language processing (NLP) model, and a recursive partitioning (RP) model. Results A total of 2,724 encounters were included in the training cohort and 793 in the validation cohort. ICD codes and NLP had good performance overall with sensitivity 91.2% and 93.1% respectively in the training cohort. However, NLP had a significant drop-off in performance in the validation cohort (sensitivity: 83.4%). The RP model had the highest sensitivity (97.2% training cohort; 94.1% validation cohort) out of the 3 methods. Figure 1. Details of encounters included in the training and validation cohorts. Table 1. Performance of ICD coding, a natural language processing (NLP) model, and a recursive partitioning (RP) model for identifying cases of acute otitis media (AOM) Conclusion Natural language processing of outpatient pediatric visit documentation can be used successfully to create models accurately identifying cases of AOM based on clinical documentation. Combining NLP and structured data can improve automated case detection, leading to more accurate assessment of antibiotic prescribing practices. These techniques may be valuable in optimizing outpatient antimicrobial stewardship efforts. Disclosures All Authors: No reported disclosures

Sign in / Sign up

Export Citation Format

Share Document