The NYS Clinical Record Initiative

2010 ◽  
Author(s):  
Robin Krajewski ◽  
Michael Hoffman
Keyword(s):  
Clinical Record

Epidemiology and clinical record of multiple sclerosis in selected countries: a systematic review

2013 ◽  
Vol 124 (5) ◽  
pp. 322-330 ◽  
Author(s):  
Natalia Niedziela ◽  
Monika Adamczyk-Sowa ◽  
Krystyna Pierzchała
Keyword(s):  
Multiple Sclerosis ◽  
Systematic Review ◽  
Clinical Record

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 Prevalence of sleep-disordered breathing related to malocclusion in children

2021 ◽  
Vol 10 (16) ◽  
pp. e598101623984
Author(s):  
Fanny Cavalcante Carrijo ◽  
Winicius Arildo Ferreira Araujo ◽  
Iorrana Morais de Oliveira ◽  
Crystina Alcântara Carvalho ◽  
Marcelo Costa Rodrigues ◽  
...  
Keyword(s):  
Sleep Disorders ◽  
Clinical Examination ◽  
Sleep Disordered Breathing ◽  
Field Research ◽  
Clinical Record ◽  
Respiratory Effort ◽  
Disordered Breathing

Sleep-disordered breathing is characterized by airway dysfunction that can occur in any age, but most prevalent in children, caused by the occurrence of respiratory effort, snoring or even by  apnea during sleep. Therefore, the aim of this study was to survey the prevalence of sleep disorders associated with malocclusion in children aged 3 to 12 years in Mineiros, State of Goiás, Brazil. Material and Methods: this is a field research with a sample of 99 children affected by some type of sleep-disordered breathing and malocclusions. Data were collected through a questionnaire about sleep-disordered breathing and a clinical record carried out through intraoral clinical examination. Results: among the 24 children with SDB, 17 had SDB and Malocclusion, which is 70.8% of the children had SDB associated with malocclusion. Of the 75 children without SDB, 11 (14.7%) had malocclusion. Conclusion: No significant differences were found between sleep-disordered breathing and sex-related malocclusions.

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