scholarly journals Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score

Cureus ◽  
2021 ◽  
Author(s):  
Baraa Mafrachi ◽  
Abdallah Al-Ani ◽  
Ashraf Al Debei ◽  
Mohamad Elfawair ◽  
Hussien Al-Somadi ◽  
...  
Keyword(s):  
Medical Documentation ◽  
Surgical Tool

scholarly journals Study in the Quality of Clinical Documentation Practice in Chitwan Medical College Teaching Hospital, Nepal

2016 ◽  
Vol 12 (2) ◽  
pp. 11-16
Author(s):  
Upendra Pandit
Keyword(s):  
Teaching Hospital ◽  
Tertiary Care ◽  
College Teaching ◽  
Final Diagnosis ◽  
Pooled Analysis ◽  
Medical Documentation ◽  
Medical College ◽  
Patient Consent ◽  
One Year

Background: Primary documentation of a patient is crucial for making effective healthcare decision and improvements in the quality of care. The objective of this study was to assess the quality of current documentation practice in tertiary care hospitals. Materials and methods: This was an assessment of medical documentation practice of one year from the period of January 2010 to December 2010 in Chitwan Medical College, Teaching Hospital. Total 184 patients' discharge files were enrolled and reviewed. Documentation was reviewed in its quality such as completeness, Coherent, consistency and Legibility.Results: In overall pooled analysis, High omission rate was observed in final diagnosis, results (cure, improved, referral and death), hospital stay, and final case summary. Although, satisfactory performance was observed in complete set of forms (72.2%); Patient consent for treatment &release authorization forms (78.2%) and treatment chart (60.8%), the overall pooled performance in ten components showed50% performance gap. Study demonstrated that documentation and its legibility, coherent and consistency in all departments needs substantial improvements in the institution.JNGMC Vol. 12 No. 2 December 2014, Page: 11-16

Work of the clinical expert department of the ophthalmosurgical clinic in the context of a pandemic of the novel coronavirus disease

2021 ◽  
pp. 9-14
Author(s):  
O.B. Baleva ◽  
◽  
N.V. Savchenko ◽  
V.V. Egorov ◽  
◽  
...  
Keyword(s):  
Social Distance ◽  
State Institution ◽  
Insurance Companies ◽  
Medical Documentation ◽  
Federal State ◽  
The Novel ◽  
Coronavirus Infection ◽  
Novel Coronavirus ◽  
Clinical Expert

Changes in work of the clinical expert department of the Khabarovsk branch of the S. Fyodorov Eye Microsurgery Federal State Institution (the Khabarovsk branch) in the context of a pandemic of the novel coronavirus disease were analyzed in the article. The difficulties that have appeared in all sections of the work performed are described, both medical and expert: the time for checking the quality of filling out medical documentation has increased due to the identification of a larger number of defects; the time for medical control and discharge of patients from the hospital has increased due to the impossibility of accumulating patients in one place and the need to maintain social distance; difficulties arose in working with experts from insurance companies due to the lack of direct communication (medical records are checked outside the Khabarovsk branch). The concern of people about the possibility of carrying out surgical treatment in conditions of coronavirus infection was expressed in an increase in the information load of the «Question - Answer» section on the website of the Khabarovsk branch and, accordingly, on the doctors in the clinical expert department working with it. Key words: pandemic, COVID-19, SARSCoV-2, anti-epidemic measures, personal protective equipment, social distance, treatment control, medical documentation, medical and economic expertise.

scholarly journals Gabapentin for the treatment of pain manifestations in children with severe neurological impairment: a single-centre retrospective review

2019 ◽  
Vol 3 (1) ◽  
pp. e000467 ◽  
Author(s):  
Aedin Collins ◽  
Rory Mannion ◽  
Annemarie Broderick ◽  
Séamus Hussey ◽  
Mary Devins ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Symptom Control ◽  
Unknown Origin ◽  
Neurological Impairment ◽  
Medical Documentation ◽  
Feeding Intolerance ◽  
Single Centre ◽  
Minimal Improvement ◽  
Severe Neurological Impairment

Pain, irritability and feeding intolerance are common symptoms affecting quality of life in children with severe neurological impairment (SNI). We performed a retrospective study to explore the use of gabapentinoid medications for symptom control in children with SNI. Patients attending the palliative care or gastroenterology department being treated with gabapentin for irritability, vomiting or pain of unknown origin were included. Information was gathered retrospectively from medical documentation. Irritability was reduced in 30 of the 42 patients included. Gabapentin was discontinued in 15 children, 12 of whom then received pregabalin. Three children had a good response to pregabalin, six a minimal improvement and three no improvement. These results support the use of gabapentinoids in this patient cohort.

Implementation of NIH Criteria for Standardization of Chronic Graft-Versus-Host Disease in Croatia: Two-Year Experience

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 5580-5580
Author(s):  
Lana Desnica ◽  
Drazen Pulanic ◽  
Ranka Serventi Seiwerth ◽  
Nikolina Matic ◽  
Marinka Mravak Stipetic ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Graft Versus Host Disease ◽  
Consensus Conference ◽  
Medical Documentation ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Organ Systems ◽  
Health Related

Abstract Background: Chronic graft-versus-host disease (cGVHD) is a disorder that affects many organ systems in highly variable fashion occurring in approximately 50% of patients following allogeneic hematopoietic stem cell transplantation (alloHSCT). It is the major cause of non-relapse morbidity and mortality after alloHSCT in individuals otherwise cured of their hematologic diseases, inducing poor quality of life, impaired functional status, inability to work, and need for ongoing chronic care, which has also important impact to health-related costs. cGVHD Consensus Conference held in 2005 at the National Institutes of Health (NIH), USA, produced recommendations regarding cGVHD diagnosis, staging, histopathology, response criteria, biomarkers, ancillary and supportive care, and design of clinical trials. In 2014, second cGVHD NIH Consensus Conference updated these recommendations, published during 2015 as 6 papers in Biology of Blood and Marrow Transplantation (BBMT) journal. Although practitioners are generally familiar with the NIH recommendations, many barriers prevent their greater uptake in clinical practice. In order to overcome these challenges, in 2013 multidisciplinary clinic infrastructure was organized at the University Hospital Center (UHC) Zagreb, Croatia, in collaboration with the NIH leading scientists, using established cGVHD-related grading scales and measurements. Methods: Division of Hematology, UHC Zagreb, Croatia, has experience with alloHSCT since 1983, and 827 patients received alloHSCT until the end of 2014. Since the establishment of multidisciplinary cGVHD team in 2013, patients were enrolled into the Unity through Knowledge Fund (UKF) study protocol (funded by World Bank and Croatian Ministry of Science, Education and Sports) and examined by multiple subspecialists, firstly seen by hematologist, with detailed history and physical exam. Standard cGVHD scoring forms are filled according to NIH Consensus recommendations, and extensive laboratory analyses were done. Patients are seen and evaluated by other sub-specialists (Dental, Dermatology, Rehabilitation, Neurology, Ophthalmology, Gynecology, and other) with further workup as needed. Quality of life questionnaires are filled during the visit. All data are collected in a specially developed database and weekly team meetings were established. Blood and small biopsy tissue samples (skin, mouth) are stored for further research. Results: Using multidisciplinary approach since 2013, 46 (6 pediatric) cGVHD patients were assesed, median age was 41 years; range [9-71], 24 were male and 22 were female. The median time from transplant to enrollment was 20 months [2-258], from cGVHD diagnosis to enrollment 7 months [0.03-234] and from transplant to cGVHD diagnosis 10 months [2-128]. Additional 17 post-alloHSCT patients were eveluated, but without confirmation of cGVHD diagnosis. Among cGVHD patients, 31 (67%) of them received transplants from matched related donors, 27 (59%) of them had myeloablative conditioning, and 26 (57%) received peripheral blood stem cells as graft source. Thirty-five (76%) patients had previous acute GVHD, 11 (24%) had de novo cGVHD, 21 (46%) quiescent and 14 (30%) progressive onset; 41 (89%) were classified as classic and 5 (11%) as overlap; 23 (50%) patients had severe, 19 (41%) moderate, and 4 (9%) mild global cGVHD score. The most involved organs were skin (54%), eyes (50%), lungs (48%) and mouth (39%). Due to internationally peer reviewed UKF grant awarded in 2013 doctoral and postdoctoral researcher were hired, and visits of young clinicians to NIH and other cGVHD centers were realized. Several new research subprojects emerged since formation of our cGVHD team and applications to the new project calls were submitted. Also, 2 international cGVHD symposiums were organized in Zagreb, Croatia, in last 2 years stimulating education and networking. Conclusion: Implementation of NIH criteria for standardizationof cGVHD in Croatia showed remarkable results, not just improving quality of medical documentation and management of these long-terms survivors with complex and long-lasting health issues, but also facilitating further international clinical research and collaboration with cGVHD community, with potential positive impact to health-related costs and benefit to society. Disclosures Nemet: Pliva: Honoraria; Janssen: Honoraria; Celgene: Honoraria; Amgen: Honoraria; Pfizer: Honoraria; Sanofi: Honoraria.

Improving the quality of the daily ward round in a Plastic Surgery unit by adapting the SAFE Ward Round Tool of the Royal College of Surgeons of Edinburgh

2020 ◽  
Vol 25 (6) ◽  
pp. 233-238
Author(s):  
Harry D Koumoullis ◽  
Martin Shapev ◽  
Gabriel Wong ◽  
Sophie Gerring ◽  
Goerge Patrinios ◽  
...  
Keyword(s):  
Plastic Surgery ◽  
Emergency Admission ◽  
Daily Practice ◽  
Ward Round ◽  
Surgical Tool ◽  
Surgical Ward ◽  
Ward Rounds ◽  
Surgery Department ◽  
Pro Forma

Aim Our goal was to audit the quality of the ward round documentation in our Plastic Surgery department by using the SAFE Ward Round Tool of the RCS Edinburgh’s as a reference standard, and to create an in-house pro-forma based on results and discussion. Method An initial cycle based on the SAFE Tool was undertaken with prospective audit of individual daily ward round entries. A sticker pro forma was introduced and re-audit was done using the same criteria. Based on results and discussion, the pro-forma was further improved. Re-audit was performed to assess percentage of completion of its contents. Results The first cycle showed 47% (n = 42) completion rate and re-audit after implementation of the sticker found a rise up to 70% (n = 42). The third cycle examining solely sticker completion yielded a compliance of 88% (n = 61). This improvement reflected to the enthusiastic comments received from staff working in allied specialties. Conclusions Significant lapses in daily ward round documentation were revealed by our methodology. A sticker pro-forma, which we have named the Surgical Tool for the Assessment of Rounds (STAR), was introduced and provided measurable and sustainable improvements on our daily ward round practice. That had as a result the safeguarding of patient safety in the frame of Good Medical Practice. We suggest same methodology to be followed based on the SAFE Ward Round Tool for surgical ward rounds improvement in all the surgical and interventional specialties particularly when there is a component of emergency admission in their daily practice

scholarly journals The STAR score: a method for auditing clinical records

2012 ◽  
Vol 94 (4) ◽  
pp. 235-239 ◽  
Author(s):  
H Tuffaha ◽  
T Amer ◽  
P Jayia ◽  
C Bicknell ◽  
N Rajaretnam ◽  
...  
Keyword(s):  
High Quality ◽  
Quality Healthcare ◽  
Surgical Tool ◽  
Finding Study ◽  
Initial Path ◽  
Audit Cycle ◽  
Medical Note ◽  
Clinical Records ◽  
Scoring Tool

INTRODUCTION Adequate medical note keeping is critical in delivering high quality healthcare. However, there are few robust tools available for the auditing of notes. The aim of this paper was to describe the design, validation and implementation of a novel scoring tool to objectively assess surgical notes. METHODS An initial ‘path finding’ study was performed to evaluate the quality of note keeping using the CRABEL scoring tool. The findings prompted the development of the Surgical Tool for Auditing Records (STAR) as an alternative. STAR was validated using inter-rater reliability analysis. An audit cycle of surgical notes using STAR was performed. The results were analysed and a structured form for the completion of surgical notes was introduced to see if the quality improved in the next audit cycle using STAR. An education exercise was conducted and all participants said the exercise would change their practice, with 25% implementing major changes. RESULTS Statistical analysis of STAR showed that it is reliable (Cronbach’s a = 0.959). On completing the audit cycle, there was an overall increase in the STAR score from 83.344% to 97.675% (p<0.001) with significant improvements in the documentation of the initial clerking from 59.0% to 96.5% (p<0.001) and subsequent entries from 78.4% to 96.1% (p<0.001). CONCLUSIONS The authors believe in the value of STAR as an effective, reliable and reproducible tool. Coupled with the application of structured forms to note keeping, it can significantly improve the quality of surgical documentation and can be implemented universally.

Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study

2008 ◽  
Vol 24 (04) ◽  
pp. 445-451 ◽  
Author(s):  
Faramarz Pourasghar ◽  
Hossein Malekafzali ◽  
Sabine Koch ◽  
Uno Fors
Keyword(s):  
Information Technology ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Medical Information ◽  
Influential Factors ◽  
Ease Of Use ◽  
Medical Documentation ◽  
Care Providers ◽  
Medical Records System

Objectives:Information technology is a rapidly expanding branch of science which has affected other sciences. One example of using information technology in medicine is the Electronic Medical Records system. One medical university in Iran decided to introduce such system in its hospital. This study was designed to identify the factors which influence the quality of medical documentation when paper-based records are replaced with electronic records.Methods:A set of 300 electronic medical records was randomly selected and evaluated against eleven checklists in terms of documentation of medical information, availability, accuracy and ease of use. To get the opinion of the care-providers on the electronic medical records system, ten physicians and ten nurses were interviewed by using of semi-structured guidelines. The results were also compared with a prior study with 300 paper-based medical records.Results:The quality of documentation of the medical records was improved in areas where nurses were involved, but those parts which needed physicians' involvement were actually worse. High workloads, shortage of bedside hardware and lack of software features were prominent influential factors in the quality of documentation. The results also indicate that the retrieval of information from the electronic medical records is easier and faster, especially in emergency situations.Conclusions:The electronic medical records system can be a good substitute for the paper-based medical records system. However, according to this study, some factors such as low physician acceptance of the electronic medical record system, lack of administrative mechanisms (for instance supervision, neglecting physicians and/or nurses in the development and implementation phases and also continuous training), availability of hardware as well as lack of specific software features can negatively affect transition from a paper-based system to an electronic system.

scholarly journals Monitoring the quality of medical documentation completion by dentists

2020 ◽  
Vol 24 (1 (93)) ◽  
pp. 222-226
Author(s):  
O. V. Rybalov ◽  
I. Yu. Lytovchenko ◽  
N. M. Ilenko ◽  
E. V. Nikolishina ◽  
I. Yu. Popovich
Keyword(s):  
Medical Documentation

scholarly journals ON THE QUESTION ORTHODONTIC MEDICAL RECORDS COMPLETION WHEN DENTOALVEOLAR ANOMALIES AND DEFORMATIONS DIAGNOSING

2017 ◽  
Vol 25 (2) ◽  
pp. 279-288
Author(s):  
A. K. Lapina ◽  
O. N. Arharova ◽  
T. S. Rodina ◽  
V. D. Vagner
Keyword(s):  
Medical Care ◽  
Medical Records ◽  
Treatment Plan ◽  
Medical Documentation ◽  
Conflict Situations ◽  
Quality Of Medical Care ◽  
Main Instrument ◽  
The Moment ◽  
Medical University

Correct registration of primary medical documentation is very important for storage of diagnostic information, the treatment plan, information about the carrying out of medical manipulations for the elimination of dentofacial anomalies, for examination of quality of medical care in conflict situations. Medical card of the orthodontic patient (form 043- 1/у), approved by order of Ministry of Health of the Russian Federation On approval of unified forms of medical records used in medical organizations providing medical care in outpatient conditions and procedures for their filling from 15.12.2014, №834 is the main document of the orthodontist. At the moment, two years after the release of the order, you need to find out whether approved new medical report form in hospitals with orthodontic care, to determine the property of filling as the main instrument used for examination of quality of medical care provided. The article presents the results of the retrospective analysis of medical cards of the patients receiving orthodontic treatment in the dental clinic at Ryazan State Medical University. Found that detailed and properly designed, only 16,0% of medical cards. Orthodontists don't pay enough attention to the medical history, examination of patients, the conduct of clinical trials and the use of special additional methods of examination of patients, such as cephalometry and functional diagnostics.

scholarly journals 531 An Admission Proforma to Improve Clerking Documentation in the ENT Department During the Covid-19 Pandemic: A Full Cycle Audit

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
G Brown ◽  
C Ashton ◽  
A Poulios
Keyword(s):  
Risk Assessment ◽  
Patient Safety ◽  
Venous Thromboembolism ◽  
Adverse Effects ◽  
Referral Source ◽  
Surgical Practice ◽  
Surgical Tool

Abstract Aim Good Surgical Practice states that surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained for all their interactions with patients. It is therefore critical that the clerking document, as the initial record of an admission, meets this standard. During the Covid-19 pandemic, an emergency rota meant that cross-covering of ENT at junior level was increasingly required in our hospital. Understandably, these trainees were less familiar with admitting ENT patients and of departmental standards. Our aim was to evaluate the quality of clerking documentation in our department during this period and investigate whether a standardised admission proforma could improve this. Method Clerking documents for all patients admitted in April 2020 were checked for completion of venous thromboembolism (VTE) risk assessment and inclusion of ten key pieces of information as outlined by the Surgical Tool for Auditing Records score. As was standard at this time, all clerking documentation had been completed on blank hospital continuation paper. A departmental admission proforma was introduced before admissions in June 2020 were then assessed identically. Results Improvement was noted in all measured parameters with no adverse effects. There was particular improvement in documentation of referral source (28% to 97%), consultant in charge (35% to 90%), name/grade/bleep (25% to 94%) and VTE risk assessment (14% to 78%). Trainee response was positive. Conclusions A simple admission proforma can markedly improve the standard of clerking documentation and therefore increase patient safety during a turbulent time. We would encourage other departments to consider developing their own.

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