Assessment of hospital inpatient discharge summaries, written for general practitioners, from a department of medicine for the elderly service in a large teaching hospital.

BACKGROUND: The discharge document summarising an acute inpatient stay in hospital is often the only means of communication between secondary and primary care. This is especially important in the elderly population who have multiple morbidities and are often on many medications. AIMS: This study aimed to assess if information important to general practitioners is being included in inpatient hospital discharge summaries for patients of the medicine for the elderly service in a large teaching hospital. METHODS: After a thorough literature review, a "gold standard" letter was defined as having included a discharge diagnosis, medications on discharge and follow-up plans. Forty computerised discharge summaries were retrospectively assessed for inclusion of these parameters. The study group consisted of the first eight sequentially discharged patients under the care of each of the five consultants during a 1-month period (1 September 2011-30 September 2011). RESULTS: A discharge diagnosis was included in 37 of the 40 summaries (92.5 %), medications on discharge were included in 39 summaries (97.5 %) and follow-up was recorded in 35 summaries (87.5 %). CONCLUSIONS: This study showed that the information assessed was available in the vast majority of discharge summaries for patients admitted acutely under the care of this medicine for the elderly service. Improvements can be made, including documentation of follow-up plans.

Problem list completeness in electronic health records: A multi-site study and assessment of success factors.

OBJECTIVE: To assess problem list completeness using an objective measure across a range of sites, and to identify success factors for problem list completeness. METHODS: We conducted a retrospective analysis of electronic health record data and interviews at ten healthcare organizations within the United States, United Kingdom, and Argentina who use a variety of electronic health record systems: four self-developed and six commercial. At each site, we assessed the proportion of patients who have diabetes recorded on their problem list out of all patients with a hemoglobin A1c elevation>=7.0%, which is diagnostic of diabetes. We then conducted interviews with informatics leaders at the four highest performing sites to determine factors associated with success. Finally, we surveyed all the sites about common practices implemented at the top performing sites to determine whether there was an association between problem list management practices and problem list completeness. RESULTS: Problem list completeness across the ten sites ranged from 60.2% to 99.4%, with a mean of 78.2%. Financial incentives, problem-oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture were identified as success factors at the four hospitals with problem list completeness at or near 90.0%. DISCUSSION: Incomplete problem lists represent a global data integrity problem that could compromise quality of care and put patients at risk. There was a wide range of problem list completeness across the healthcare facilities. Nevertheless, some facilities have achieved high levels of problem list completeness, and it is important to better understand the factors that contribute to success to improve patient safety. CONCLUSION: Problem list completeness varies substantially across healthcare facilities. In our review of EHR systems at ten healthcare facilities, we identified six success factors which may be useful for healthcare organizations seeking to improve the quality of their problem list documentation: financial incentives, problem oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture.

[Detection of temporomandibular joint diseases in elderly and senile age in ambulatory medicoprophylactic institutions].

The research analyzes diagnostic TMJ's disease's identification work of stomalogists owned to different types of day care properties (municipal, departmental, private). This research based on examination of primary medical records of 1906 patients aged 61 to 89 years, including 2978 prescribing lists made by stomatologists - orthopedists to dental outpatient's card. This research shows that in case of outpatient conditions in the primary examination of patients of elderly and senile age stomatologists pay attention to joint pathology in the presence of acute patients' complaints, caused by TMJ's displacement, arthritis, painful TMJ's dysfunction or pronounced sound phenomena of TMJ. Stomatologists examine TMJ's pathology more particularly. The TMJ's pathology complicates the tooth replacement made to patients contrary to absence of indications of disease presence in primary medical records. The prepared conclusion and recommendations allow improving the outpatient diagnosis of TMJ's pathology.

Proyecto "Prevención y detección precoz de discapacidades en barrios urbano-marginales La Primavera

La Dirección Nacional de Rehabilitación Integral del Minusválido (DINARIM), del Ministerio de Bienestar Social financia un proyecto de investigación acción en el barrio La Primavera sobre: "Prevención y Detección Precoz de Discapacidades en Barrios Urbano Marginales". Siendo la unidad ejecutora el Centro Cipriana Dueñas de la Facultad de Ciencias Médicas de la Universidad Central. Los objetivos del proyecto son básicamente la educación a la comunidad para la detección precoz de las discapacidades, la prevención y el manejo adecuado de una red de referencia para que la población en el futuro sea responsable de mantenerla. Durante el proyecto se estableció una unidad base de atención en La Primavera Alta. Los sectores aledaños: La Primavera Baja, San Vicente y Mulanga que formaban parte del Proyecto fueron visitados casa a casa. Se identificaron factores de riesgo de discapacidades como la ubicación geográfica, en las laderas del Pichincha, al borde de la quebrada que atraviesa el sector, el tipo de construcciones, las condiciones inadecuadas de saneamiento ambiental, el difícil acceso a unidades de salud y las bajas coberturas del control prenatal como del niño pequeño. Se aplicó una encuesta a 639 familias y se obtuvo información sobre condiciones de vivienda y saneamiento ambiental. Así 63 por ciento viven en casa, siendo propietarios un 62 por ciento, porcentaje en el ecual se incluyen los de la zona de invasión de Mulanga. Para la eliminación de excretas un 25 por ciento de las familias utiliza letrinas y campo abierto y el 11 por ciento eliminan la basura en terrenos baldíos en la quebrada o en la calle. Se observó que un 30 por ciento de las viviendas tenían mala higiene estas condiciones aumenta las probabilidades de producir enfermedades infecciosa y parasitarias.

Documentation in home health care practice. Evidence of quality care.

Documentation in home care has become an increasingly important part of the nursing role. This article discusses some common problems with the written word encountered by nurses. A research study on documentation done in an urban home care agency is also presented.

Statistical quality control in nursing homes: a key indicator to evaluate patient incontinence care.

The authors provide descriptive data regarding incontinence care within the framework of statistical quality control technology. Descriptive data of patient wetness frequencies were collected for 126 incontinent patients from six nursing homes in Middle Tennessee under conditions guaranteeing that they were checked and changed on a two-hour basis. One hundred inspection subsamples were randomly selected for five incontinent-patient sample sizes: 10, 15, 20, 25, and 30 patients. The average and expected variability of patient wetness frequency was calculated for each of these subsamples. These measures help nursing homes determine if they are in compliance with state and federal regulations regarding the timeliness of incontinence care. The authors suggest how nursing home management and regulatory agencies can use statistical quality control techniques.

ICD, POR, and DRG. Unsolved scientific problems in the nosology of clinical medicine.

A system of scientific classification should have a suitable basic axis of organization, standardized names, clearly specified operational criteria, and multiaxial arrangements for citing important attributes beyond those included in the basic axis. During the past century, the main nosologic system for identifying human ailments has been the International Classification of Diseases (ICD), which has a well-organized and well-accepted nomenclature, but which lacks operational criteria and an appropriate multiaxial pattern. Two new systems of classification during the past two decades are intended for other purposes and would not be satisfactory as nosologic substitutes. The Problem-Oriented Record (POR) does not have a standardized nomenclature or criteria; and the Diagnosis-Related Group (DRG) approach was organized mainly for fiscal goals. As the basic taxonomy used for classifying human ailments, the ICD needs substantial improvement to fulfill its scientific role in statistics for the occurrence and treatment of disease.

Assessing the problem-oriented approach to care delivery.

It is evident that there is wide difference of opinion about the utility of the problem-oriented approach to health care delivery. Review of the literature on the subject suggests that ongoing debate over the merits of the approach has been fueled by incomplete information about important elements of the problem-oriented philosophy. This essay discusses the arguments for and against the approach, attempts to explain how misunderstandings have limited previous efforts to assess the manual problem-oriented record, and suggests implications for the study of both manual and computerized applications of the problem-oriented approach to care delivery.

Concordance between medical records and observations regarding information on coordination of care.

This study was designed to determine the extent to which the medical record contained evidence of coordination of care. Coordination of care was defined as the recognition of information (problems, therapies, intervening visits and tests) about patients from one visit to a follow-up visit. Overall, there was concordance between the medical record and independent observation of the physician-patient interaction in 70-85 per cent of instances. When there was clear indication that the practitioner recognized the information, the chart contained evidence of this recognition 68-85 per cent of the time, depending on the type of information. However, if the information was highly salient, the record contained evidence of recognition in a much greater percentage of intances: 95 per cent for distinctly identified problems, 83 per cent for problems which were contained within the text of progress notes, 96 per cent for major drugs, and 94 per cent for abnormal tests. The data from this study support the less direct evidence of others that the medical record adequately reflects extent of recognition of important information about patients by practitioners.

[A practical clinical record system for the general practitioner]. / 'n praktiese kliniese rekordstelsel vir die huisarts.

Owing to the multidisciplinary character of general practice, there is a great need for an effective and practical clinical record system for the family physician. The recording of clinical data of home visits and other visits places an extra burden on his record system. A practical system which tries to solve these and other problems is presented. A simplified form of Weed's Problem Orientated Medical Records (POMR) is incorporated in this system. The different components as well as the practical functioning of the system are described.

A psychiatric POMR for use by a multidisciplinary team.

A psychiatric problem-oriented medical record designed for use by multidisciplinary teams was introduced at Fairfield Hills Hospital in Newtown, Connecticut, in 1972. The need for revision in the hospital's medical record system had been pointed up by the development of the teams, which shared more equally in responsibility for patient care, and by problems in meeting Medicare standards. The authors describe the various forms that make up the POMR. Most of the forms are completed by the teams in regularly scheduled conferences.