Clinically accessible tools for documenting the impact of orthostatic intolerance on symptoms and function in ME/CFS.

BACKGROUND: Clinical observations have indicated that hours of upright activity (HUA) reported by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients correlated with orthostatic symptoms and impaired physical function. This study examined the relationship between HUA and orthostatic intolerance (OI). METHODS: Twenty-five female ME/CFS subjects and 25 age and race matched female healthy controls (HCs) were enrolled. Subjects reported HUA (defined as hours per day spent with feet on the floor) and completed questionnaires to assess the impact of OI on daily activities and symptoms. ME/CFS patients were categorized into those with <5 HUA and ≥5 HUA and analyzed by employment status. Data analysis used one-way ANOVA. RESULTS: ME/CFS patients had fewer HUA, worse symptoms and greater interference with daily activities due to OI than HCs. The <5 HUA ME/CFS subjects had more severe OI related symptoms than ≥5 HUA ME/CFS subjects even though OI interfered with daily activities similarly. Only 33% of ME/CFS subjects were employed and all were ≥5 HUA ME/CFS subjects with an average HUA of 8. CONCLUSIONS: ME/CFS subjects experienced more frequent and severe OI symptoms, higher interference with daily activities, and reduced ability to work than HCs. Reported HUA and assessment of OI using standardized instruments may be useful clinical tools for physicians in the diagnosis, treatment and management of ME/CFS patients.

Documenting disability in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).

BACKGROUND: According to the 2015 National Academy of Medicine report, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) "is a serious, chronic, complex, and systemic disease that frequently and dramatically limits the activities of affected patients." ME/CFS affects between 1 and 2.5 million Americans, leaving as many as 75% unable to work due to physical, cognitive and functional impairment. Unfortunately, many doctors and lawyers lack the knowledge of how to properly document an ME/CFS disability claim, leaving patients unable to access disability benefits. OBJECTIVE: The goal of this article is to summarize the approaches used by experienced clinicians and lawyers in successful ME/CFS disability claims. METHODS: The authors reviewed the types of US disability insurance programs and the evidence commonly required by these programs to demonstrate ME/CFS disability. RESULTS: This article summarizes the range of methods used in successful US disability claims, which include documentation of the functional impact of post-exertional malaise and the use of methods that provide objective evidence of impairment. CONCLUSIONS: Medical providers and lawyers can use these tested methods to obtain disability benefits for people with ME/CFS. Physical therapists, occupational therapists, and other specialists play an important role in providing objective evidence for ME/CFS disability claims.

Developing Structured Omaha System Goals for Use in an Electronic Health Record.

Use of standardized terminology has been essential for clear, concise, and accurate documentation of client assessments, care plans, and outcomes. The purpose of this study was to create standardized language goals for a case management system that used the Omaha System. A group of nursing informaticists analyzed, refined, and developed revised goals evaluated using medical vocabulary properties. A set of unique goals aligned with the Omaha System was developed with specifically designed characteristics and functionality that allowed individualization and evaluation of goal attainment. Goal statements and ratings were standardized and written to reflect goals a client could attain. The Omaha System goals served as a template for nurse case managers to use in telephonic support with clients and future development of new goals and allowed the organization the ability to generate quality metrics.

Clinical Documentation and Patient Care Using Artificial Intelligence in Radiation Oncology.

Detailed clinical documentation is required in the patient-facing specialty of radiation oncology. The burden of clinical documentation has increased significantly with the introduction of electronic health records and participation in payer-mandated quality initiatives. Artificial intelligence (AI) has the potential to reduce the burden of data entry associated with clinical documentation, provide clinical decision support, improve quality and value, and integrate patient data from multiple sources. The authors discuss key elements of an AI-enhanced clinic and review some emerging technologies in the industry. Challenges regarding data privacy, regulation, and medicolegal liabilities must be addressed for such AI technologies to be successful.

Changes in Electronic Health Record Use Time and Documentation over the Course of a Decade.

PURPOSE: With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption. DESIGN: Single-center cohort study. PARTICIPANTS: Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers. METHODS: We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models. MAIN OUTCOME MEASURES: Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters. RESULTS: Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010. CONCLUSIONS: After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues.

Introduction of an electronic patient record (EPR) improves operation note documentation: the results of a closed loop audit and proposal of a team-based approach to documentation.

An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of England's Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should include. This study aimed to assess if the introduction of an electronic patient record (EPR) improved the quality of general surgical operation notes. An annonymised retrospective case note review of general surgical operation notes was undertaken over five separate time periods. The first cycle consisted of periods 1 (prior to EPR implementation), 2 (1 week after EPR) and 3 (4 weeks after EPR). Period 4 was a reaudit 2 weeks after the initial results were presented at the local governance meeting. The cycle was then closed with period 5; 1 year after EPR implementation. A comparison was across all 5 time periods for compliance with the RCS guidelines and with subanalysis of the individual categories. 250 operation notes were reviewed during five time periods. Compliance improved by almost 19% (p=0.0003) between periods 1 and 5. Eleven of the 19 points (57.9%) over the audit period achieved 100% compliance post-EPR compared to 0% prior. Poor compliance were noted in the categories of antibiotic use, venous thromboembolism prophylaxis and estimated blood loss (noting that these are often documented in the anaesthetic record and/or WHO checklist). EPRs do not guarantee compliance with GSP. We propose that GSP standards need to be updated to reflect the modernisation of medical records and a team-based approach with multimodality input sources would achieve better patient records and patient care.

Coding Discrepancies Between Medical Student and Physician Documentation.

OBJECTIVE: Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation. DESIGN: Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level of service (LOS) and diagnostic code by trained, expert coders. Differences in LOS and diagnostic code were then compared between medical student and faculty documentation. SETTING: A single academic health system. PARTICIPANTS: Third-year medical students. RESULTS: 80 full patient evaluations and 20 postoperative visits were analyzed. Median faculty and student LOS was 4 (range 3-4) and 3 (range 0-4) respectively (p < 0.001). Students failed to document a sufficient number of elements in the evaluation, failed to specify studies ordered, and documented low medical decision making. Diagnostic code was concordant between students and faculty for only 31% of documentation. CONCLUSION: Student documentation of clinical encounters is coded at a lower LOS than faculty documentation. These results likely reflect the lack of education regarding E/M coding in medical school, which is integral to real world practice. SUMMARY: Accurate medical documentation is critical to the correct diagnostic coding and billing of a medical encounter. We found that compared to faculty documentation of the same patient evaluations, student documentation was typically coded at a lower level of service and assigned a different diagnostic code by professional medical coders. Addressing these topics in medical school may better prepare students for real-world practice.

Current and Emerging Options for Documenting Scars and Evaluating Therapeutic Progress.

BACKGROUND: Current studies on pathological scarring often rely on subjective means. The identification and implementation of objective documentation standards are of high priority. OBJECTIVE: To identify, describe, and evaluate current and upcoming options for objective scar documentation. METHODS: The authors analyzed imaging options (ultrasound, PRIMOS, and optical coherence tomography) and scales/questionnaires (Visual Analog Scale, Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, and Dermatology Life Quality Index) based on the existing literature and described their application for scar documentation. RESULTS: A variety of capable options for the documentation of scars are available. None of these, however, seem suitable as a stand-alone tool for scar documentation. CONCLUSION: A combination of objective imaging tools in combination with questionnaires and scar scales may be warranted to achieve comprehensive documentation during everyday clinical work and in regard to a higher level of evidence in future research.

Agenesias múltiplas e microdontia / Multiple agenesis and microdontia ­ a case report

Nowadays, esthetics has guided patients to seek for dental treatment. Tooth development anomalies are an important category of morphologic variations and malocclusions. Tooth agenesis, also described as congenital absence, is characterized by numeric tooth reduction. It is one of the most frequent changes in the human being and originates from disturbances at tooth formation initiation and proliferation, being classified as hipodontia, oligodontia, or anodontia. On the other hand, microdontia is characterized by smaller teeth, involving the entire arch or a tooth group. Conoid or microteeth compromise the smile and lead patients to seek for dental treatment. Microdontia can be seen as a series of histological changes at the epithelial tooth structure during enamel organ formation, with the final tooth smaller than the normal values. As dental professionals, we must guide patients for better treatment ways. This paper aimed to present a clinical case involving multiple tooth agenesis and microdontia, highlightening the etiology, prevalence, and treatment of these anomalies.

Reduced Circumferential Resection Margin Involvement in Rectal Cancer Surgery: Results of the Dutch Surgical Colorectal Audit.

BACKGROUND: The circumferential resection margin (CRM) is a significant prognostic factor for local recurrence, distant metastasis, and survival after rectal cancer surgery. Therefore, availability of this parameter is essential. Although the Dutch total mesorectal excision trial raised awareness about CRM in the late 1990s, quality assurance on pathologic reporting was not available until the Dutch Surgical Colorectal Audit (DSCA) started in 2009. The present study describes the rates of CRM reporting and involvement since the start of the DSCA and analyzes whether improvement of these parameters can be attributed to the audit. METHODS: Data from the DSCA (2009-2013) were analyzed. Reporting of CRM and CRM involvement was plotted for successive years, and variations of these parameters were analyzed in a funnelplot. Predictors of CRM involvement were determined in univariable analysis and the independent influence of year of registration on CRM involvement was analyzed in multivariable analysis. RESULTS: A total of 12,669 patients were included for analysis. The mean percentage of patients with a reported CRM increased from 52.7% to 94.2% (2009-2013) and interhospital variation decreased. The percentage of patients with CRM involvement decreased from 14.2% to 5.6%. In multivariable analysis, the year of DSCA registration remained a significant predictor of CRM involvement. CONCLUSIONS: After the introduction of the DSCA, a dramatic improvement in CRM reporting and a major decrease of CRM involvement after rectal cancer surgery have occurred. This study suggests that a national quality assurance program has been the driving force behind these achievements.

Documentação ortodôntica digitalizada – ainda precisamos de papel? / Electronic orthodontic records – we still need papers?

Muitos dos processos de diagnóstico e planejamento no consultório de Ortodontia contemporâneo têm ocorrido de maneira digitalizada. Exames, anteriormente gerados apenas em suporte de papel, têm sido entregues ao profissional em formato digital e até enviados pela internet. Acompanhando essas transformações técnicas, muitos ortodontistas sonham em ter um consultório inteiramente informatizado, com todos os dados disponíveis em qualquer momento por acesso remoto. Com os avanços tecnológicos, a possibilidade da digitalização do prontuário físico, bem como do uso dos sistemas informatizados, se apresentam como excelentes opções para a manutenção da documentação odontológica. Além da evidente relevância clínica e administrativa, uma boa documentação é reconhecida como a melhor forma de defesa de um profissional quando sua conduta é colocada à prova. Neste contexto, é preciso que o ortodontista entenda os critérios técnicos e legais para incorporação dos meios digitais à sua rotina. O objetivo deste trabalho foi discutir as exigências legais da utilização de prontuários eletrônicos por especialistas em Ortodontia, bem como apresentar os aspectos práticos a serem considerados no caso da digitalização de documentos elaborados na clínica com o objetivo de armazenamento...

Many of the diagnostic and planning processes in contemporary orthodontic office has been digitized and many exams previously generated on paper has been delivered entirely digital and sent over the internet. Accompanying these technical changes, many orthodontists dream of having a fully digitized office, with all the information available at any time via remote access. With technological advances, the possibility of scanning physical records and the use of computerized systems, stand as excellent options for maintaining dental records. Apart from the obvious clinical and administrative relevance, a good documentation is recognized as the best form of defense of a professional when their conduct is questioned. In this context, it is necessary that the orthodontist understand the technical and legal criteria for incorporation of digital media to your routine. The objective of this paper is to discuss the legal requirements the use of electronic medical records by orthodontic specialists, as well as presenting practical aspects to be considered in the case of document scanning developed in the clinic with the purpose of storage...

Screening children for autism in an urban clinic using an electronic M-CHAT.

BACKGROUND: The Modified Checklist for Autism in Toddlers (M-CHAT) is a screening tool for autism spectrum disorders in the clinic. However, the follow-up questions in the M-CHAT are difficult to implement on a paper format. OBJECTIVE: To compare the effectiveness of the M-CHAT on an electronic format versus paper format in an outpatient clinic setting. Methods. A prospective study used electronic M-CHAT on the iPad. A retrospective review of paper M-CHATs 6 months prior to implementation was used as the comparison group. RESULTS: A total of 176 participants completed the electronic M-CHAT format and 197 paper M-CHATs were retrospectively reviewed. The electronic format (3%) resulted in a significant difference in the frequency of children found to be at risk for autism compared with the paper version (11%); 99% of parents rated the experience as "good" or "excellent." CONCLUSION: The electronic format lowered both false at-risk screens and false not-at-risk screens and had higher parental satisfaction.

Validação jurídica do prontuário odontológico eletrônico: proposta fundamentada na legislação brasileira / Legal validation of electronic dental records: a proposal based on Brazilian Legislation

Introdução: buscando aliar a utilização de recursos tecnológicos digitais com a segurança jurídica, o objetivo do presente trabalho é viabilizar, por meio de conceitos da Ciência do Direito, uma proposta para validação jurídica do “Prontuário Odontológico Eletrônico”. Métodos: como no Ordenamento Jurídico brasileiro não há legislação específica sobre esse assunto, a questão foi analisada conforme a analogia, os costumes e os princípios gerais de direito. Resultados e Conclusões: é possível obter “Prontuário Odontológico Eletrônico” com a mesma validade jurídica do “Prontuário Odontológico Convencional”. Para tanto, o cirurgião-dentista, o laboratório de radiologia e o paciente devem assinar digitalmente os arquivos da documentação digital que tenham responsabilidade de assinar na documentação convencional não-digital.

Drug allergy documentation--time for a change?

OBJECTIVE OF THE STUDY: To audit patients' allergy documentation in a large rural hospital an to make recommendations about accurate drug allergies in hospital settings. SETTING: A 257 bed large hospital and fully integrated health service in Australia, providing a range of services including; medicine, surgery, aged care, cancer care, mental health, maternity and rehabilitation. METHOD: A retrospective design was used to fulfil the aims of this study. Patient medical records were randomly selected and checked for allergy documentation over a 6 month period. RESULTS: A total of 521 patients' medical records were reviewed. Of all the medical records examined in total, 269 (52%) had no allergy, while 252 (48%) reported some kind of allergy. Overall, only three patients (0.6%) had their allergy details fully and accurately recorded in the three places audited and they are the front cover of the patients' notes, the admission notes and the drug chart. CONCLUSION: Many preventable medical errors are caused by poor documentation which is often due to lack of drug allergy information. All health professional should be more pro-active in determining the manner of any drug allergy or adverse drug reactions (ADR) along with the extent of the reaction.