scholarly journals Organ donation performance in the Netherlands 2005-08; medical record review in 64 hospitals

2010 ◽  
Vol 25 (6) ◽  
pp. 1992-1997 ◽  
Author(s):  
N. E. Jansen ◽  
H. A. van Leiden ◽  
B. J. J. M. Haase-Kromwijk ◽  
A. J. Hoitsma
Keyword(s):  
The Netherlands ◽  
Organ Donation ◽  
Medical Record ◽  
Medical Record Review ◽  
Record Review

scholarly journals Diagnosis and treatment of patients with antiphospholipid syndrome: a mixed-method evaluation of care in The Netherlands

2020 ◽  
Vol 4 (2) ◽  
Author(s):  
Mirthe J Klein Haneveld ◽  
Caro H C Lemmen ◽  
Tammo E Brunekreef ◽  
Marc Bijl ◽  
A J Gerard Jansen ◽  
...  
Keyword(s):  
The Netherlands ◽  
Focus Groups ◽  
Medical Record ◽  
Medical Records ◽  
Quantitative Methods ◽  
Medical Record Review ◽  
Anticoagulant Treatment ◽  
Medical Specialists ◽  
Record Review ◽  
Fragmentation Of Care

Abstract Objectives The aims were to gain insight into the care provided to patients with APS in The Netherlands and to identify areas for improvement from the perspective of both patients and medical specialists. Methods APS care was evaluated using qualitative and quantitative methods. Perspectives on APS care were explored using semi-structured interviews with medical specialists, patient focus groups and a cross-sectional, online patient survey. In order to assess current practice, medical records were reviewed retrospectively to collect data on clinical and laboratory manifestations and pharmacological treatment in six Dutch hospitals. Results Fourteen medical specialists were interviewed, 14 patients participated in the focus groups and 79 patients completed the survey. Medical records of 237 patients were reviewed. Medical record review showed that only one-third of patients were diagnosed with APS within 3 months after entering specialist care. The diagnostic approach and management varied between centres and specialists. Almost 10% of all patients and 7% of triple-positive patients with thrombotic APS were not receiving any anticoagulant treatment at the time of medical record review. Correspondingly, poor recognition and fragmentation of care were reported as the main problems by medical specialists. Additionally, patients reported the lack of accessible, reliable patient education, psychosocial support and trust in physicians as important points for improvement. Conclusion Delayed diagnosis, variability in management strategies and fragmentation of care were important limitations of APS care identified in this study. A remarkable 10% of patients did not receive any anticoagulant treatment.

scholarly journals Limited external reproducibility restricts the use of medical record review for benchmarking

2019 ◽  
Vol 8 (2) ◽  
pp. e000564
Author(s):  
Dorthe O Klein ◽  
Roger Rennenberg ◽  
Rijk Gans ◽  
Roelien Enting ◽  
Richard Koopmans ◽  
...  
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
The Netherlands ◽  
Medical Record ◽  
Medical Records ◽  
Medical Record Review ◽  
Quality And Safety ◽  
Internal Review ◽  
Record Review ◽  
Kappa Agreement

BackgroundMedical record review (MRR) is used to assess the quality and safety in hospitals. It is increasingly used to compare institutions. Therefore, the external reproducibility should be high. In the current study, we evaluated this external reproducibility for the assessment of an adverse event (AE) in a sample of records from two university medical centres in the Netherlands, using the same review method.MethodsFrom both hospitals, 40 medical records were randomly chosen from patient files of deceased patients that had been evaluated in the preceding years by the internal review committees. After reviewing by the external committees, we assessed the overall and kappa agreement by comparing the results of both review rounds (once by the own internal committee and once by the external committee). This was calculated for the presence of an AE, preventability and contribution to death.ResultsKappa for the presence of AEs was moderate (k=0.47). For preventability, the agreement was fair (k=0.39) and poor for contribution to death (k=−0.109).ConclusionWe still believe that MRR is suitable for the detection of general issues concerning patient safety. However, based on the outcomes of this study, we would advise to be careful when using MRR for benchmarking.

scholarly journals Validation of ICD-10-CM codes for injuries complicating pregnancy, childbirth and the puerperium: a medical record review

2021 ◽  
Vol 27 (Suppl 1) ◽  
pp. i9-i12
Author(s):  
Anna Hansen ◽  
Dana Quesinberry ◽  
Peter Akpunonu ◽  
Julia Martin ◽  
Svetla Slavova
Keyword(s):  
Emergency Department ◽  
Medical Record ◽  
International Classification Of Diseases ◽  
Medical Record Review ◽  
Full Sample ◽  
Emergency Department Data ◽  
Classification Of Diseases ◽  
Icd 10 ◽  
Record Review

IntroductionThe purpose of this study was to estimate the positive predictive value (PPV) of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for injury, poisoning, physical or sexual assault complicating pregnancy, childbirth and the puerperium (PCP) to capture injury encounters within both hospital and emergency department claims data.MethodsA medical record review was conducted on a sample (n=157) of inpatient and emergency department claims from one Kentucky healthcare system from 2015 to 2017, with any diagnosis in the ICD-10-CM range O9A.2-O9A.4. Study clinicians reviewed medical records for the sampled cases and used an abstraction form to collect information on documented presence of injury and PCP complications. The study estimated the PPVs and the 95% CIs of O9A.2-O9A.4 codes for (1) capturing injuries and (2) capturing injuries complicating PCP.ResultsThe estimated PPV for the codes O9A.2-O9A.4 to identify injury in the full sample was 79.6% (95% CI 73.3% to 85.9%) and the PPV for capturing injuries complicating PCP was 72.0% (95% CI 65.0% to 79.0%). The estimated PPV for an inpatient principal diagnosis O9A.2-O9A.4 to capture injuries was 90.7% (95% CI 82.0% to 99.4%) and the PPV for capturing injuries complicating PCP was 88.4% (95% CI 78.4% to 98.4%). The estimated PPV for any mention of O9A.2-O9A.4 in emergency department data to capture injuries was 95.2% (95% CI 90.6% to 99.9%) and the PPV for capturing injuries complicating PCP was 81.0% (95% CI 72.4% to 89.5%).DiscussionThe O9A.2-O9A.4 codes captured high percentage true injury cases among pregnant and puerperal women.

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