medication-documentation-in-nursing-discharge-summaries-at-patient-discharge-from-special-care-to-primary-care

2014 ◽  
Vol 03 (02) ◽  
Author(s):  
Anne Kuusisto
1995 ◽  
Vol 34 (04) ◽  
pp. 345-351 ◽  
Author(s):  
A. Burgun ◽  
L. P. Seka ◽  
D. Delamarre ◽  
P. Le Beux

Abstract:In medicine, as in other domains, indexing and classification is a natural human task which is used for information retrieval and representation. In the medical field, encoding of patient discharge summaries is still a manual time-consuming task. This paper describes an automated coding system of patient discharge summaries from the field of coronary diseases into the ICD-9-CM classification. The system is developed in the context of the European AIM MENELAS project, a natural-language understanding system which uses the conceptual-graph formalism. Indexing is performed by using a two-step processing scheme; a first recognition stage is implemented by a matching procedure and a secondary selection stage is made according to the coding priorities. We show the general features of the necessary translation of the classification terms in the conceptual-graph model, and for the coding rules compliance. An advantage of the system is to provide an objective evaluation and assessment procedure for natural-language understanding.


2010 ◽  
Vol 01 (01) ◽  
pp. 1-10 ◽  
Author(s):  
S. E. Ross ◽  
B. K. Mellis ◽  
B. L. Beaty ◽  
L. M. Schilling ◽  
A. J. Davidson ◽  
...  

SummaryObjective: Assess the interest in and preferences of ambulatory practitioners in HIE.Background: Health information exchange (HIE) may improve the quality and efficiency of care. Identifying the value proposition for smaller ambulatory practices may help those practices engage in HIE.Methods: Survey of primary care and specialist practitioners in the State of Colorado.Results: Clinical data were commonly (always [2%], often [29%] or sometimes [49%]) missing during clinic visits. Of 12 data types proposed as available through HIE, ten were considered “extremely useful” by most practitioners. “Clinical notes/consultation reports,” “diagnosis or problem lists,” and “hospital discharge summaries” were considered the three most useful data types. Interest in EKG reports, diagnosis/problem lists, childhood immunizations, and discharge summaries differed among ambulatory practitioner groups (primary care, obstetrics-gynecology, and internal medicine subspecialties).Conclusion: Practitioners express strong interest in most of the data types, but opinions differed by specialties on what types were most important. All providers felt that a system that provided all data types would be useful. These results support the potential benefit of HIE in ambulatory practices.


2013 ◽  
Vol 6 (1) ◽  
pp. 83-89 ◽  
Author(s):  
Peter A. Polyzotis ◽  
Neville Suskin ◽  
Karen Unsworth ◽  
Robert D. Reid ◽  
Veronica Jamnik ◽  
...  

Author(s):  
Adriéli Donati Mauro ◽  
Danielle Fabiana Cucolo ◽  
Marcia Galan Perroca

ABSTRACT Objective: To analyze how the articulation between hospital and primary health care related to patient discharge and continuity of care after hospitalization takes place. Method: Qualitative study, using the focus group technique to explore the experience of 21 nurses in hospitals (n = 10) and at primary care (n = 11) in a municipality in the northwest area of the State of São Paulo. Data collection took place between December 2019 and April 2020. Four focus groups were carried out (two in the hospital and two in the health units) and the findings underwent thematic analysis. Results: The categories identified were: Patient inclusion flow in the responsible discharge planning, Patient/family member/caregiver participation, Care planning, Communication between services, and Challenges in the discharge process. According to reports, the discharge process is centered on bureaucratic aspects with gaps in communication and coordination of care. Conclusion: This research allowed understanding how nurses from different points of health care experience the discharge and (dis)articulation of the team work. The findings can equip managers in the (re)agreement of practices and integration of services to promote continuity of care.


2010 ◽  
Vol 01 (01) ◽  
pp. 1-10 ◽  
Author(s):  
S. E. Ross ◽  
B. K. Mellis ◽  
B. L. Beaty ◽  
L. M. Schilling ◽  
A. J. Davidson ◽  
...  

SummaryObjective: Assess the interest in and preferences of ambulatory practitioners in HIE.Background: Health information exchange (HIE) may improve the quality and efficiency of care. Identifying the value proposition for smaller ambulatory practices may help those practices engage in HIE.Methods: Survey of primary care and specialist practitioners in the State of Colorado.Results: Clinical data were commonly (always [2%], often [29%] or sometimes [49%]) missing during clinic visits. Of 12 data types proposed as available through HIE, ten were considered “extremely useful” by most practitioners. “Clinical notes/consultation reports,” “diagnosis or problem lists,” and “hospital discharge summaries” were considered the three most useful data types. Interest in EKG reports, diagnosis/problem lists, childhood immunizations, and discharge summaries differed among ambulatory practitioner groups (primary care, obstetrics-gynecology, and internal medicine subspecialties).Conclusion: Practitioners express strong interest in most of the data types, but opinions differed by specialties on what types were most important. All providers felt that a system that provided all data types would be useful. These results support the potential benefit of HIE in ambulatory practices.


2019 ◽  
Vol 49 (1) ◽  
pp. 46-51
Author(s):  
Aline Hurtaud ◽  
François Lallier ◽  
Matthieu Heidet ◽  
Charline Arnoult ◽  
Moustapha Dramé ◽  
...  

Abstract Background hospital discharge is a critical event for older patients. The French guidelines recommended the swift transmission of a discharge summary to the general practitioner (GP) and a primary care consultation within 7 days. The relevance and feasibility of these guidelines have not previously been assessed. Objective to perform a real-life assessment of compliance with French guidelines on the transmission of discharge summaries and post-discharge medical reviews and to examine these factors’ association with 30-day readmissions. Design a prospective multicentre cohort study. Setting primary care (general practice) in France. Subjects a sample of GPs and the same number of patients aged 75 or over having consulted within 30 days of hospital discharge. Methods the main endpoints were the proportion of discharge summaries available and the proportion of patients consulting their GP within 7 days. The 30-day readmission rate was also measured. Factors associated with these endpoints were assessed in univariate and multivariate analyses. Results seventy-one GPs (mean ± standard deviation age: 49 ± 11; males: 62%) and 71 patients (mean age: 84 ± 5; males: 52%; living at home: 94%; cognitive disorders: 22%) were included. Forty-six patients (65%, [95% confidence interval [CI]]: 53–76) consulted their GP within 7 days of hospital discharge. At the time of the consultation, 27 GPs (38% [95% CI]: 27–50) had not received the corresponding hospital discharge summary. Discharge summary availability was associated with a lower risk of 30-day readmission (adjusted odds ratio [95% CI] = 0.25 [0.07–0.91]). Conclusions compliance with the French guidelines on hospital-to-home transitions is insufficient.


2012 ◽  
Vol 13 (1) ◽  
Author(s):  
Matthew D Olson ◽  
Gretchen L Tong ◽  
Beat D Steiner ◽  
Anthony J Viera ◽  
Evan Ashkin ◽  
...  

1999 ◽  
Vol 22 (1-2) ◽  
pp. 383-395
Author(s):  
Pierre Zweigenbaum

We present experiments performed with intex to process medical terms. One of our aims is to identify terms in patient discharge summaries that denote diagnoses and procedures, in order to help in the coding of these diagnoses and procedures in the context of the French national coding programme (pmsi). Some of the experiments presented here have been performed on corpora of the menelas project (P. Zweigenbaum & Consortium menelas 1995) or in the framework of the dome project (B. Séroussi et al. 1996). We have built for this purpose specialised lexica which contain specific semantic features. The search for relevant terms is then performed through regular expressions that make use of these features. For these experiments, intex was mainly used in the form of pipes of Unix filters called through a “ Makefile ”, the principles of which we also briefly present.


2022 ◽  
pp. 115-127
Author(s):  
Sagar Sudhir Dhobale ◽  
Sharda Bapat

ICD (international classification of diseases) is a system developed by the WHO in which every unique diagnosis and procedure has a unique code. It provides a standardized way to represent medical information and makes it sharable and comparable across different hospitals and countries. Currently, the task of assigning ICD codes to patient discharge summaries is performed manually by medical coders. Manual coding is costly, time consuming, and inefficient for huge data. So, the healthcare industry requires automated solutions to make the medical coding more efficient, accurate, and consistent. In this study, the automated ICD-9 coding is approached as a multi-label text classification problem. A deep learning system is presented to assign ICD-9 codes automatically to the patient discharge summaries. Convolutional neural networks and word2vec model are combined to automatically extract features from the input text. The best model has achieved 83.28% accuracy. The results of this research prove the usability of deep learning for multi-label text classification and medical coding.


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