scholarly journals Improving recording and reporting of dementia and frailty via electronic patient record by ambulance staff in a single service (IDEAS)

2021 ◽  
Vol 6 (3) ◽  
pp. 31-40
Author(s):  
Patryk Jadzinski ◽  
Helen Pocock ◽  
Chloe Lofthouse-Jones ◽  
Phil King ◽  
Sarah Taylor ◽  
...  
Keyword(s):  
Electronic Patient Record ◽  
Care Pathway ◽  
Information Provision ◽  
Patient Record ◽  
Care Staff ◽  
Open Questions ◽  
Diagnosis Of Dementia ◽  
Reduced Mobility ◽  
Subsequent Patient ◽  
Staff Practice

Background: Dementia is common in older adults assessed by ambulance services. However, inconsistent reporting via the patient record may result in this diagnosis being overlooked by healthcare staff further down the care pathway. This can have a deleterious effect on subsequent patient care, increasing morbidity and mortality. We sought to understand how and where ambulance staff would like to record this finding on the electronic patient record (ePR).Methods: We designed and implemented a survey of ambulance staff in a single service to understand how they identify patients with dementia, how they record dementia on the ePR and how the ePR could be improved to better capture dementia. Scoping questions on frailty were included. The survey was tested using cognitive interviewing. Analysis was conducted using descriptive statistics for closed questions and thematic analysis for open questions as appropriate.Results: 131 surveys were completed; 60% of participants were paramedics and 40% were other grades of front line staff. Participants reported consulting electronic/paper sources, and individuals such as carers involved in the patients’ care, to establish whether dementia had been diagnosed. Frailty assessments were prompted by social context, reduced mobility, a fall or diagnosis of dementia. Staff reported documenting dementia in 20 different areas on the ePR and 46% of participants stated a preference for a designated area to record the information. However, 15% indicated it was not necessary to record dementia or that no ePR changes were required.Conclusions: We have highlighted the variation in ambulance staff practice in recording of dementia. Alterations to the ePR are required to ensure that dementia is recorded consistently and is easily retrievable. Clearer guidance on when to assess frailty may also enhance information provision to care staff in other sectors, resulting in more appropriate clinical and social care.

P6135Improving detection of AF: insights from real world screening programme

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Khan ◽  
H Butt ◽  
A Khokhar ◽  
A Orlowski ◽  
B Porter ◽  
...  
Keyword(s):  
Primary Care ◽  
At Risk ◽  
Electronic Patient Record ◽  
Screening Programme ◽  
Smart Phone ◽  
Patient Record ◽  
Care Staff ◽  
Health And Social Care ◽  
Care Practices ◽  
Primary Care Practices

Abstract Background AF related stroke places a significant burden on individuals, carers and health and social care systems. The observed prevalence of AF in populations is often lower than expected and this results in high rates of AF diagnosis at the time of the stroke event. Opportunistic screening for AF in at risk populations is recommended by ESC, however, is often missed due to time constraints and lack of expertise. Technological advancements such as m-health ECG monitors can aid in the diagnosis of AF with improvements in timely risk assessment and initiation of protective anticoagulation. Purpose The purpose of this study was to determine whether introduction of a suite of m-health tools including electronic patient record based tools and smart phone based ECG recording could improve the rates of AF detection and subsequently reduce the rate of AF related strokes. Methods The study was conducted in a city region with a population of around 300 000, served by 48 primary care practices. The project involved a three staged approach; education and support for primary care staff, creating an “at-risk” register on primary care electronic patient record for those over 60 or with relevant co-morbidities associated with electronic prompts for screening and a standardized assessment template and the roll-out of smart phone based single-lead ECG monitors to facilitate rhythm checks. The population was followed over a 4 year period to monitor rates of AF diagnosis, anticoagulation and stroke rates. Results The study population were male (53%), aged between 30–39 (22.4%) and were of white ethnicity (40%). At baseline, in 2014, the prevalence of AF was 0.89% (2492 individuals). By 2018, this had increased to 1.1% (3328 individuals) with on average 40 new diagnoses of AF compared to 26 in the baseline period (see figure).Anticoagulation prescription within 30 days of diagnosis increased from 29.80% to 50.00% whilst prescription of antiplatelet monotherapy within same time period decreased from 12.73% to 6.4%. This was also associated with a reduction in the proportion of strokes seen in the population secondary to AF with 35% (n=143) of strokes secondary to AF in 2014 and 25% (n=127) secondary to AF in 2017. Conclusion The study found that implementation of a screening programme across a wide range of primary care practices led to an improvement in AF diagnosis, management and timeliness of care. This highlights the benefit of using simple methods such as GP educations in conjunction with new technology device to detect AF more effectively and subsequently treat in an appropriate and time-effective fashion. In our population this appears to be associated with real reductions in AF related strokes Acknowledgement/Funding CLAHRC NWL, NHS Hounslow CCG, Pfizer

Improving Coded Data Entry by an Electronic Patient Record System

1996 ◽  
Vol 35 (02) ◽  
pp. 108-111 ◽  
Author(s):  
F. Puerner ◽  
H. Soltanian ◽  
J. H. Hohnloser
Keyword(s):  
Phase I ◽  
Electronic Patient Record ◽  
Data Entry ◽  
Discharge Summary ◽  
Patient Record ◽  
Phase Iii ◽  
Electronic Patient Record System ◽  
Record System ◽  
Data Encoding ◽  
Discharge Summaries

AbstractData are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may “shift” as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby “bypassing” the need to encode, this was reduced by up to 41 % with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.

Development of an advanced database for clinical trials integrated with an electronic patient record system

2011 ◽  
Vol 41 (8) ◽  
pp. 575-586 ◽  
Author(s):  
Alexander C. Newsham ◽  
Colin Johnston ◽  
Geoff Hall ◽  
Michael G. Leahy ◽  
Adam B. Smith ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Electronic Patient Record ◽  
Patient Record ◽  
Electronic Patient Record System ◽  
Record System

Linking a web based electronic patient record with a DICOM PACS

2001 ◽  
Vol 1230 ◽  
pp. 801-804
Author(s):  
J. Reponen ◽  
J. Niinimäki ◽  
T. Leinonen ◽  
J. Korpelainen ◽  
J. Oikarinen ◽  
...  
Keyword(s):  
Electronic Patient Record ◽  
Patient Record ◽  
Web Based

SP10.2.12 Information Sustainability: The revitalisation and upcycling of 373,342 historic surgical pathology records into the contemporary electronic patient record in one UK NHS Hospital Trust

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Fatima Rahman ◽  
Alan Hales ◽  
David Cable ◽  
Keith Burrill ◽  
Adrian Bateman ◽  
...  
Keyword(s):  
Electronic Patient Record ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Patient Record ◽  
Clinical Use ◽  
Data Resource ◽  
Cancer Data ◽  
Transition Points ◽  
Pathology Reports ◽  
Cellular Pathology

Abstract Aims Surgical and Cellular pathology (‘e-pathology’) record sets are a valuable data resource with which to populate the Electronic Patient Record (EPR). Accessible reports, even decades old, can be of great value in contemporary clinical decision making and as a resource for longitudinal clinical research. They commonly identify the operation, the location and the pathology, even if not to modern reporting standards. Methods Since 2010, we have built and implemented a timeline structured EPR for the ‘whole-of-life’ visualisation of the electronic documents (e-Docs) of 2.5M+ patients on our Master Index. Prior to this project, our earliest e-Docs dated to 1995. We tracked down 373,342 inert e-pathology reports from our legacy Ferranti (1990-1997) and Masterlab (1997-2004) systems. These were uploaded into our active file servers, following appropriate data quality and patient identity reconciliation checks. Results We have progressively restored 373,342 previously inaccessible e-pathology records to clinical use and to immediacy of access, and in the process extending our “addressable EPR” back to 1990 for living and deceased patients. This process has also allowed us to populate and validate an EPR-integral breast cancer data system of 20,000 cases with e-pathology records dating back to 1990. Conclusions The sustainable revitalisation of old e-pathology reports into a timeline structured EPR creates preserves and upcycles the investment in pathology reporting which is otherwise progressively lost to clinical use. E-pathology records provide reliable, life-long evidence of critical transition points in individual lives and disease progression for clinical and research use, when they can be instantly accessed.

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