ABSTRACT
Objetivo: identificar características clínicas das paradas cardiopulmonares e reanimações cardiopulmonares ocorridas em ambiente intra-hospitalar. Método: estudo quantitativo, prospectivo e observacional, a partir de informações de prontuários de pacientes submetidos a manobras de reanimação devido à parada cardiopulmonar entre janeiro e dezembro de 2021. Utilizou-se um instrumento baseado nas variáveis do modelo de registro Utstein. Resultados: em 12 meses foram registradas 37 paradas cardiopulmonares. A maioria ocorreu na unidade de terapia intensiva respiratória, com causa clínica mais prevalente hipóxia. 65% dos pacientes foram intubados no atendimento e 57% apresentaram ritmo atividade elétrica sem pulso. A duração da reanimação variou entre menos de cinco a mais de 20 minutos. Como desfecho imediato, 57% sobreviveram. Conclusão: dentre os registros analisados, a maior ocorrência de paradas cardiopulmonares foi na unidade de terapia intensiva respiratória, relacionada à Covid-19. Foram encontrados registros incompletos e ausência de padronização nas condutas.
Objective: identify the clinical characteristics of cardiopulmonary arrests and cardiopulmonary resuscitations in the in-hospital environment. Method: this is a quantitative, prospective and observational study based on information from the medical records of patients who underwent resuscitation maneuvers due to cardiopulmonary arrest between January and December 2021. An instrument based on the variables of the Utstein registration protocol was used. Results: thirty-seven cardiopulmonary arrests were recorded in 12 months. The majority occurred in a respiratory intensive care unit, with hypoxia being the most prevalent clinical cause. Sixty-five percent of the patients were intubated and 57% had pulseless electrical activity. The duration of resuscitation ranged from less than five to more than 20 min. As for the immediate outcome, 57% survived. Conclusion: among the records analyzed, the highest occurrence of cardiopulmonary arrests was in respiratory intensive care units, and they were related to Covid-19. Moreover, incomplete records and a lack of standardization in cardiopulmonary resuscitation procedures were found.
Objetivo: Identificar las características clínicas de paros cardiopulmonares y reanimaciones cardiopulmonares que ocurren en un ambiente hospitalario. Método: estudio cuantitativo, prospectivo y observacional, realizado a partir de información presente en historias clínicas de pacientes sometidos a maniobras de reanimación por paro cardiorrespiratorio entre enero y diciembre de 2021. Se utilizó un instrumento basado en las variables del modelo de registro Utstein. Resultados: en 12 meses se registraron 37 paros cardiopulmonares. La mayoría ocurrió en la unidad de cuidados intensivos respiratorios, la causa clínica más prevalente fue la hipoxia. El 65% de los pacientes fue intubado durante la atención y el 57% presentaba un ritmo de actividad eléctrica sin pulso. La duración de la reanimación varió entre menos de cinco y más de 20 minutos. Como resultado inmediato, el 57% sobrevivió. Conclusión: entre los registros analizados, la mayor cantidad de paros cardiopulmonares se dio en la unidad de cuidados intensivos respiratorios, relacionada con Covid-19. Se encontraron registros incompletos y falta de estandarización en el procedimiento.
ABSTRACT
RESUMEN Objetivo: Desarrollar una revisión de artículos para evaluar la evidencia sobre la tecnología blockchain aplicada en la medicina. Métodos: El estudio es de tipo documental, diseño bibliográfico, enmarcado en una revisión sistemática. La recolección de los artículos se realizó en las bases de datos Scopus, Web of Sciences, Pro Quest y SienceDirect, desde el 1 de enero de 2018 hasta el 31 de julio de 2023. Los descriptores fueron blockchain, tecnología y medicina. Se elaboró el diagrama PRISMA y se consideró los criterios de inclusión: artículos originales, con acceso abierto que aborden el tema y en cualquier idioma. Se hallaron 70 artículos, de los cuales 11 conformaron la muestra. Resultados: Se analizaron las diversas aplicaciones de la tecnología blockchain en la medicina, entre ellas su integración con inteligencia artificial (IA) para el análisis centrado en datos; en cuanto al desarrollo de sistemas de trazabilidad, sin embargo, su mayor aplicabilidad está en el registro de historias médicas de pacientes, cuya aplicación fue exitosa. A pesar de esto, se comprobó su uso incipiente, en la medicina, debido a la ausencia de estudios al respecto. Conclusiones: La aplicación de la tecnología blockchain en la medicina es muy escasa, a pesar del potencial que posee para el registro y resguardo de datos médicos; por lo tanto, se debe profundizar el estudio de la misma.
ABSTRACT Objective: Develop an articles review to evaluate the existing evidence on blockchain technology applied in medicine. Methods: The study was of a documentary type, bibliographic design, framed in a systematic review. The harvest of articles was carried out in the Scopus, Web of Sciences, Pro Quest and ScienceDirect databases from January 1, 2018 to July 31, 2023. The descriptors were blockchain, technology and medicine. The PRISMA diagram was prepared considering the inclusion criteria: original articles, with open access; that address the subject and in any language. The search yielded 70 articles, of which 11 formed the sample. Results: The various applications of blockchain technology in medicine were discussed, including its integration with artificial intelligence (AI) for data-centric analysis; regarding the development of traceability systems, however, its greatest applicability is in the registration of medical records of patients, whose application was successful. Despite this, its incipient use in medicine was verified due to the lack of studies in this regard. Conclusions: The application of blockchain technology in medicine is very scarce, despite the potential it has for the registration and safeguarding of medical data, therefore, its study should be deepened.
ABSTRACT
Aproximar os estudantes das funcionalidades, potencialidades e das limitações das tecnologias para o registro eletrônico em saúde (RES) é necessário e urgente, a fim de prepará-los para futura atuação profissional. Os registros constituem memória valiosa para o profissional, instituição de saúde e paciente, sendo importante ferramenta na integralidade e longitudinalidade das informações para a tomada de decisão. Neste sentido, este estudo tem por objetivo desenvolver e avaliar uma plataforma web para o ensino e aprendizagem de registros eletrônicos, no cenário da Atenção Primária em Saúde (APS). Como percurso metodológico esta pesquisa foi conduzida em três etapas, sendo a 1° etapa o Planejamento; a 2° etapa o Desenvolvimento da plataforma utilizando-se do referencial metodológico do desenvolvimento ágil de software, na modalidade Scrum. E por fim, na 3° etapa, a Avaliação pelos estudantes de Enfermagem e Medicina, professores e especialistas em Tecnologias da Informação e Comunicação (TIC), por meio de questionários: Teste de Aceitação; escala System Usability Scale (SUS); recomendação do produto pelo escore Net Promoter e avaliação da inter-relação das funcionalidades do registro eletrônico e competências-chave, pautadas na Taxonomia de Bloom. A análise dos dados foi realizada por meio de estatística descritiva. Participaram da etapa de avaliação um total de 34 estudantes, 14 professores e 9 especialistas em TIC. Foram pontuadas oportunidades de melhorias na tela de agendamento e nas telas de atendimento do paciente, nos itens referentes ao registro de dados objetivos, avaliação e plano de cuidados. Por meio da SUS observou-se que a plataforma apresenta usabilidade adequada aos objetivos propostos. No Net Promoter Score é possível observar que a maioria dos avaliadores classificaram a plataforma na zona de excelência. Em relação à avaliação dos professores acerca da interrelação das funcionalidades do registro eletrônico para APS e competências-chave, conforme o ano de curso, é possível inferir a possibilidade de contribuição com o desenvolvimento de competências no processo de aprendizado em registros eletrônicos em saúde. Conclui-se que, por meio da plataforma, é possível que o estudante vivencie a experiência imersiva ao realizar as mesmas tarefas de um registro eletrônico no cenário da APS, utilizando banco de dados de pacientes simulados. Destaca-se que a construção e avaliação da plataforma corrobora com a necessidade de desenvolver competências em RES, buscando preparar os estudantes de Enfermagem e Medicina para a documentação adequada das informações inerentes ao cuidado em saúde, aspecto fundamental para a prática clínica.
Aproximar os estudantes das funcionalidades, potencialidades e das limitações das tecnologias para o registro eletrônico em saúde (RES) é necessário e urgente, a fim de prepará-los para futura atuação profissional. Os registros constituem memória valiosa para o profissional, instituição de saúde e paciente, sendo importante ferramenta na integralidade e longitudinalidade das informações para a tomada de decisão. Neste sentido, este estudo tem por objetivo desenvolver e avaliar uma plataforma web para o ensino e aprendizagem de registros eletrônicos, no cenário da Atenção Primária em Saúde (APS). Como percurso metodológico esta pesquisa foi conduzida em três etapas, sendo a 1° etapa o Planejamento; a 2° etapa o Desenvolvimento da plataforma utilizando-se do referencial metodológico do desenvolvimento ágil de software, na modalidade Scrum. E por fim, na 3° etapa, a Avaliação pelos estudantes de Enfermagem e Medicina, professores e especialistas em Tecnologias da Informação e Comunicação (TIC), por meio de questionários: Teste de Aceitação; escala System Usability Scale (SUS); recomendação do produto pelo escore Net Promoter e avaliação da inter-relação das funcionalidades do registro eletrônico e competências-chave, pautadas na Taxonomia de Bloom. A análise dos dados foi realizada por meio de estatística descritiva. Participaram da etapa de avaliação um total de 34 estudantes, 14 professores e 9 especialistas em TIC. Foram pontuadas oportunidades de melhorias na tela de agendamento e nas telas de atendimento do paciente, nos itens referentes ao registro de dados objetivos, avaliação e plano de cuidados. Por meio da SUS observou-se que a plataforma apresenta usabilidade adequada aos objetivos propostos. No Net Promoter Score é possível observar que a maioria dos avaliadores classificaram a plataforma na zona de excelência. Em relação à avaliação dos professores acerca da interrelação das funcionalidades do registro eletrônico para APS e competências-chave, conforme o ano de curso, é possível inferir a possibilidade de contribuição com o desenvolvimento de competências no processo de aprendizado em registros eletrônicos em saúde. Conclui-se que, por meio da plataforma, é possível que o estudante vivencie a experiência imersiva ao realizar as mesmas tarefas de um registro eletrônico no cenário da APS, utilizando banco de dados de pacientes simulados. Destaca-se que a construção e avaliação da plataforma corrobora com a necessidade de desenvolver competências em RES, buscando preparar os estudantes de Enfermagem e Medicina para a documentação adequada das informações inerentes ao cuidado em saúde, aspecto fundamental para a prática clínica.
Subject(s)
Primary Health Care , Educational Technology , Electronic Health Records , Interprofessional EducationABSTRACT
Objective The purpose of this article is to analyze the problem with the first page of inpatient medical re-cords in the Department of Bone and Soft Tissue Oncology of a certain hospital,in order to provide guidance for improving the quality of the first page of inpatient medical records.Methods A retrospective analysis was conducted on 2 979 inpatient medi-cal records from the Department of Bone and Soft Tissue Oncology of a certain hospital from April 1,2022 to August 31,2023.Excel was used to statistically analyze and record the occurrence of problems on the first submission of inpatient medical records.Results A total of 1 258 inpatient medical records had issues with the first submission of 2 979 inpatient medical records,with an incidence rate of 42.23％.A total of 2 149 defects were found on the homepage of 1 258 problematic medical records,among which 28.71％,22.57％,16.66％,13.49％,and 10.89％were other diagnostic errors,main diagnostic errors,pathological diagnostic errors,other surgical or operational errors,and main surgical or operational errors,respectively.Conclusion There are many pre quality inspection issues on the first page of inpatient medical records in the Department of Bone and Soft Tissue On-cology of a certain hospital,which should be taken seriously.The incidence rate can be reduced by strengthening training for clin-ical physicians,providing targeted guidance for coding personnel on filling out problems on the first page,improving pre submis-sion logic quality control in the Information Department,and strengthening performance evaluation.
ABSTRACT
Objective To analyze the role of the key items list in the quality control of running medical records by com-paring the improvements of the quality of medical records,and to explore more effective ways of quality management of medical records.Methods Based on the goal setting theory and influencing factors of goal incentive utility,a list of key items for medi-cal record quality management was formulated,which was implemented in a children's hospital in Tianjin since April 2023.A to-tal of 4 823 operating medical records were collected from June 2022 to September 2023,and the defect rates of quality control items were compared by using statistical methods.Results After the implementation of the key items list,the average score of operating medical records was improved,and the defect rate decreased from 13.63％to 7.94％.Moreover,the defect rates of admission records,first-trip records,senior physician rounds records,consultation records,and surgical records decreased from 4.25％,3.07％,8.26％,and 10.56％to 1.61％,1.56％,4.41％,and 5.06％.Conclusion The implementation of key i-tems list management can effectively improve the quality of running medical records,reduce the defects of medical records,and improve the effects of medical record management.
ABSTRACT
Objective To enhance the data quality of the front page of inpatient medical records.Methods Ten coders were engaged to perform manual quality control,and system verification rules were integrated for the basic information,diagnosis,treatment information,and hospitalization process information on the front page of inpatient medical records before and after the implementation of grid management.Results A total of 808 defects were found on the front pages of 728 inpatient medical re-cords.Among these deficiencies,basic information,diagnosis and treatment information,and process information accounted for 40.84％,3.96％,and 55.20％respectively.Totally,282 defects on the front pages of the 796 inpatient medical records man-aged under grid management.Among them,basic information,diagnosis and treatment information,and process information ac-counted for 39.00％,7.80％,and 53.19％,respectively.The overall defect rate was significantly decreased under grid manage-ment compared to the rate without it,(x2=6.553 5,P＜0.05).After the implementation of grid management,the numbers of the defects in admission condition,ID number incompletion,incision healing status,and coding were significantly decreased(P＜0.05).After the normalized coding of the ID number,the defect in ID number incompletion on the pages disappeared con-sequently.Conclusion Grid management reduces communication and feedback time,improves the data quality of the front page of inpatient medical records,and enhances problem-solving efficiency.It is important to coordinate the control of the data on the front pages of inpatient medical records to enhance standardization,consistency,and integrity.Moreover,it can also be applied to other areas of hospital management,offering scientific methods to optimize overall hospital operations.
ABSTRACT
Purpose/Significance The paper discusses the application of artificial intelligence technology to the key entity recognition ofunstructured text data in the electronic medical records of lymphedema patients.Method/Process It expounds the solution of model fine-tuning training under the background of sample scarcity,a total of 594 patients admitted to the department of lymphatic surgery of Beijing Shijitan Hospital,Capital Medical University are selected as the research objects.The prediction layer of the GlobalPointer model is fine-tuned according to 15 key entity categories labeled by clinicians,nested and non-nested key entities are identified with its glob-al pointer.The accuracy of the experimental results and the feasibility of clinical application are analyzed.Result/Conclusion After fine-tuning,the average accuracy rate,recall rate and Macro_F1 ofthe model are 0.795,0.641 and 0.697,respectively,which lay a foundation for accurate mining of lymphedema EMR data.
ABSTRACT
Objective To build a knowledge graph;To visualize the knowledge structure relationships and clinical thinking in the treatment of coronary heart disease by renowned TCM doctors;To provide methodological reference for the inheritance of experience of renowned TCM doctors.Methods Medical records about treatment of coronary heart disease by renowned TCM doctors were retrieved from CNKI from the establishment of the database to 30th,Nov.2022.The characteristics of TCM diagnosis and treatment and the characteristics of the theoretical system of syndrome differentiation and treatment in TCM were analyzed.Concept types and relationships between concepts were sorted out and extracted to form a pattern layer of knowledge graph;based on the characteristics of the pattern layer,Python 3.11(PyCharm 2022.3.2)was used to write rules,and knowledge extraction and data import were implemented through the Pandas library,Openpyxl library and Py2neo library,which were stored in the graph database Neo4j-Community-5.2.0 to complete the construction of the knowledge graph.Implementing query application was realized through Cypher language.Results The data of 643 medical cases of 144 renowned TCM doctors were included,which were entered into the Neo4j graph database,forming a knowledge graph consisting of 2 744 nodes and 23 795 relationships under 8 concepts and 10 relationships,to achieve visual presentation and query application of the diagnosis and treatment process of coronary heart disease by renowned TCM doctors.Conclusion The knowledge graph can intuitively display the relationship of diseases-symptoms-syndromes-treatments-prescriptions-medicine in medical records,develop a knowledge system that is easy to retrieve,and improve the accessibility of domain knowledge,which can provide methodological reference for the inheritance of experience of renowned TCM doctors.
ABSTRACT
[Objective]To summarize Professor SHU Qijin's academic experience in diagnosing and treating salty taste in the mouth after anti-tumor therapy.[Methods]Through learning from teacher in outpatient,reading ancient books and analyzing the medical records,this paper arranged Professor SHU's medical records of salty taste in the mouth after anti-tumor therapy and introduced his clinical experience in treating that from following aspects:etiology and pathogenesis,principles and laws of treatment,and provided one medical case as evidence.[Results]Professor SHU believes that salty taste in the mouth after anti-tumor therapy is closely related to overgrowth of the kidney fluid due to the imbalance of Yin and Yang and dampness caused by unrestriction of water-liquid metabolism of the kidney and spleen,and briefly summarizes the treatment principles in three aspects:reconciling and replenishing Yin and Yang of the kidney,invigorating the spleen and eliminating dampness.The attached medical record was identified as fire excess from Yin deficiency and damp abundance.Professor SHU treated the case by nourishing Yin and reducing fire as well as invigorating the spleen and eliminating dampness,modified Zhibai Dihuang Pill and Pingwei Powder was used for treatment and good results were achieved.[Conclusion]In the treatment of salty taste in the mouth after anti-tumor therapy,Professor SHU adheres to comprehensive analysis by the four examination methods and advocates flexible syndrome differentiation.Professor SHU's academic experience is rich and clinical curative effect is remarkable.Summarizing his medication characteristics has high guiding significance for the clinical application.
ABSTRACT
[Objective]To summarize the clinical experience of Director CHEN Yongcan in the treatment of postoperative complications of anorectal disease from the liver and spleen.[Methods]Through learning from teachers,collecting clinical medical cases,reviewing relevant literature,analyzing the relationship between liver and spleen and anorectum,the key pathogenesis and main treatment methods of this disease were proposed,and the clinical experience of Director CHEN in treating postoperative complications of anorectal disease from the liver and spleen was expounded,and three medical cases were attached for evidence.[Results]Director CHEN believes that the postoperative complications of anorectal disease are closely related to liver and spleen disorders,and the disease is located in the anorectum,and the liver and spleen are responsible.The relationship between anorectum and liver and spleen reflects in three aspects:physiological communication,functional connection and five elements correlation,and the key pathogenesis is liver and spleen discord and Qi imbalance,and the treatment advocates starting from the liver and spleen,with the three methods of rising,clearing and nourishing,harmonizing the liver and spleen,regulating the Qi movement,and promoting the recovery of anorectal function after surgery.The cited medical cases included the treatment of postoperative constipation of mixed hemorrhoids by raising the spleen and soothing the liver,the treatment of postoperative abdominal distension of anal fistula by clearing the liver and promoting the spleen,and the treatment of postoperative diarrhea of rectal cancer by nourishing the spleen and softening the liver,all of which achieved good therapeutic effects.[Conclusion]Director CHEN has rich experience in the treatment of postoperative complications of anorectal disease from the liver and spleen,which is practical and worthy of promotion.
ABSTRACT
[Objective]To summarize the academic experience of Professor ZENG Qingqi in the use of classical prescription in the diagnosis and treatment of insomnia combined with reproductive system diseases.[Methods]Through clinical follow-up studying,reading ancient books,Professor ZENG's clinical experience in treating insomnia and reproductive system diseases was analyzed from the aspects of the treatment of insomnia with classical prescription,the treatment ideas of reproductive system diseases with classical prescription,and the concept of homotherapy for heteropathy in Chinese medicine for insomnia combined with reproductive system diseases,which was supported by medical cases.[Results]Professor ZENG's treatment of insomnia combined with reproductive system diseases follows the concept of homotherapy for heteropathy in Chinese medicine,advocating the use of the"five differentiation"diagnostic and treatment mode based on Chinese medicine viewpoint,such as body differentiation,disease differentiation,syndrome differentiation,local differentiation and micro differentiation,and paying attention to promoting medication according to the situation,combining warming and clearing,dredging and tonifying.It is believed that the key to the effectiveness of classical prescription in treating insomnia combined with reproductive system diseases lies in dealing with the problems of"suppressing hyperactivity"and"releasing",emphasizing the reconciliation between the relationship of heart(brain),heart and kidney,and not only dredging to treat the symptoms,but also cultivating and replenishing to treat the root cause.The patient in case one was of insomnia combined with impotence,identified as liver depression and Qi stagnation,spleen and kidney deficiency syndrome,modified Sini Powder and Shenqi Pills was used in treatment.Case two was of insomnia combined with menstruation,identified as disconnection of the heart and kidney,deficiency cold of Chong Ren and blood stasis blocking the uterus,treated with Huanglian Ejiao Decoction and Zhizishi Decoction combined with Wenjing Decoction.Both used classical prescriptions and achieved good results.[Conclusion]Professor ZENG specializes in the treatment of insomnia combined with reproductive system diseases with the use of meridian prescription,flexible identification,and appropriate prescription,with precise efficacy,its rich clinical experience is worth clinical learning and further promotion.
ABSTRACT
[Objective]To explore the specificity and effectiveness of Medical Records Integration of Palace in Qing Dynasty for the treatment of diseases,and to provide a reference for the modern clinical external therapy.[Methods]Taking 117 fumigating and washing decoctions in Medical Records Integration of Palace in Qing Dynasty as the research object,using Excel software,the formulas,dosage,medicinal properties,and efficacy of Qinggong fumigating and washing decoctions were organized and counted.Combining with the relevant medical cases and the commentaries in the book,the use of the fumigating and washing decoctions in the Qing Palace was systematically organized.[Results]The 117 fumigating and washing decoctions in Medical Records Integration of Palace in Qing Dynasty show many features such as there are many kinds of formula,the quality of the formula is refined;the effect is strength and special focus,formula with modification according to symptoms,flexible usage of medicine,treatment first,independent use of the amount of medicine,good use of the wind-extinguishing medicinal,filling in the poisonous features when needed.It also has other advantages such as a wide range of audiences,a unique approach,sophisticated instruments,and a meticulous process of preparation of the liquid.[Conclusion]The use of the fumigating and washing decoctions in Medical Records Integration of Palace in Qing Dynasty has palace characteristics and advantages,exploring its use can gain unique insights and revelations,which helps to carry forward the characteristics of court medication and promotes the development of external therapeutic methods of traditional Chinese medicine as high research value.
ABSTRACT
Objetivo: Describir la reflexión autocrítica que médicos especialistas en medicina interna hacen de la calidad del registro de la información en la historia clínica electrónica, en el Hospital Pablo Tobón Uribe. Metodología: Estudio cualitativo que aplicó técnicas de la teoría fundamentada, con entrevistas semiestructuradas en profundidad a quince médicos internistas de un hospital de alta complejidad en Medellín, Colombia. El análisis partió de una conceptualización con codificación abierta y, luego, se hizo la agrupación de códigos en categorías descriptivas. Se identificaron propiedades y dimensiones que fueron relacionadas mediante la codificación axial con la matriz del paradigma de la teoría fundamentada, que permitió la emergencia de una categoría más abstracta. Resultados: Los entrevistados manifestaron que la historia clínica guarda información fundamental e invaluable, que contribuye al mejoramiento de la sa¬lud de los pacientes. Relacionaron la calidad del diligenciamiento de la historia clínica con un contexto regulatorio nacional, el cual tiene exigencias administrativas y financieras que ejercen presión de requerimientos externos a la clínica sobre su diligenciamiento. Se reconoce la influencia de la cultura digital y del inmediatismo, debilidades en la formación del diligenciamiento de la historia clínica tanto en pregrado y posgrado. Lo anterior distancia al médico del paciente, genera desmotivación en el ejercicio de su profesión y facilita cometer errores. Conclusiones: Existe una contradicción entre el "deber ser" del diligenciamiento con calidad de la historia clínica y lo que sucede en la práctica, pues su intencionalidad original de ser una herramienta al servicio de la asistencia clínica se desvirtúa, al privilegiar el haberse convertido en un instrumento que responde a otros factores externos del sistema de salud del país.
Objective: to describe the self-critical reflection that internal medicine specialists make on the quality of the information recorded in the electronic medical record in a high complexity hospital. Methodology: qualitative study that applied Grounded Theory techniques, with semi-structured in-depth interviews to fifteen internists of the Pablo Tobón Uribe Hospital in Colombia. The analysis was based on a conceptualization with open coding and then grouping of codes into descriptive categories. Properties and dimensions were identified and related through axial coding with the matrix of the Grounded Theory paradigm, which allowed the emergence of a more abstract category. Results: the interviewees informed the medical records keeps invaluable and fundamental information which contributes to the improvement of patient Ìs health. They related the quality of medical records fill out with a national regulatory context, which has administrative and financial challenges that demands external pressure over the completion requirements in the medical assistance. The influence of digital culture and immediacy and insufficiencies skills in undergraduate and postgraduate medical training for a comprehensive fill out medical records, are recognized. The above distances the physician from the patient, generates demotivation in the practice of his profession and makes it easier to make mistakes. Conclusions: there is a contradiction between the "should be" of the quality of the medical records and what happens in practice, since its original intention of being a tool at the service of clinical care is distorted, as it has become a tool that responds to other external factors to the National health system.
Objetivo: Descrever a reflexão autocrítica que os médicos especialistas em medicina interna fazem sobre a qualidade da informação registrada no prontuário eletrônico do Hospital Pablo Tobón Uribe. Metodologia: Estudo qualitativo que aplicou técnicas de teoria fundamentada, com entrevistas semiestruturadas em profundidade com quinze internos de um hospital de alta complexidade em Medellín, Colômbia. A análise partiu de uma conceituação com codificação aberta e, em seguida, foi feito o agrupamento dos códigos em categorias descritivas. Foram identificadas propriedades e dimensões que se relacionaram por meio da codificação axial com a matriz do paradigma da teoria fundamentada, o que permitiu o surgimento de uma categoria mais abstrata. Resultados: Os entrevistados relacionaram a qualidade do preenchimento da história clínica com um contexto regulatório que impõe exigências administrativas e financeiras que exercem pressão de exigências externas à clínica no seu preenchimento. Reconhece-se a influência da cultura digital e do imediatismo, as insuficiências na formação médica graduada e pós-graduada e as limitações dos médicos nas habilidades de comunicação. Isso distancia o médico do paciente, gera desmotivação no exercício de sua profissão e facilita erros. Conclusões: Existe uma contradição entre o "deveria ser" de preencher a anamnese com qualidade e o que ocorre na prática, pois sua intenção original de ser uma ferramenta a serviço do atendimento clínico é desvirtuada, ao privilegiar ter se tornado um instrumento que responde a outros fatores externos ao ato médico e às exigências administrativas do sistema de saúde.
ABSTRACT
Purpose: To describe the demographics and clinical profile of pseudoexfoliation syndrome (PXF or PES) in patients presenting to a multi?tier ophthalmology hospital network in India. Methods: This cross?sectional hospital?based study included 3,082,727 new patients presenting between August 2010 and December 2021. Patients with a clinical diagnosis of PXF in at least one eye were included as cases. The data were collected using an electronic medical record system. Results: Overall, 23,223 (0.75%) patients were diagnosed with PXF. The majority of the patients were male (67.08%) and had unilateral (60.96%) affliction. The most common age group at presentation was during the seventh decade of life with 9,495 (40.89%) patients. The overall prevalence was higher in patients from a lower socio?economic status (1.48%) presenting from the urban geography (0.84%) and in retired individuals (3.61%). The most common location of the PXF material was the pupillary margin (81.01%) followed by the iris (19.15%). The majority of the eyes had mild or no visual impairment (<20/70) in 12,962 (40.14%) eyes. PXF glaucoma was documented in 7,954 (24.63%) eyes. Krukenberg’s spindle was found in 64 (0.20%) eyes, phacodonesis in 328 (1.02%) eyes, and lens subluxation in 299 (0.93%) eyes. Among the surgical interventions, cataract surgery was performed in 8,363 (25.9%) eyes, trabeculectomy was performed in 966 (2.99%) eyes, and a combined procedure in 822 (2.55%) eyes. Conclusion: PXF more commonly affects males presenting during the seventh decade of life from lower socio?economic status and is predominantly unilateral. A quarter of the affected eyes are associated with glaucoma and the majority of the eyes have mild or no visual impairment.
ABSTRACT
RESUMEN Objetivo : el presente estudio tuvo como objetivo determinar la calidad del registro de las historias clínicas odontológicas de un centro de salud de la ciudad de Ica, Perú. Material y métodos : Se realizó un estudio descriptivo, con un enfoque cuantitativo, no experimental, observacional, transversal y retrospectivo. La muestra estuvo conformada por 212 historias clínicas que fueron evaluadas mediante la Norma Técnica de Salud n.° 029-MINSA/DIGEPRES-V.02, aprobada por la Resolución Ministerial n.° 502-2016/MINSA, norma que permitió evaluar distintos aspectos con puntajes. Luego de realizar la sumatoria del puntaje obtenido se procedió a calificar. Resultados : Se obtuvo que, entre las historias clínicas del centro de salud de la ciudad de Ica, el 53,8 % tuvo una calidad por mejorar; 42 %, una calidad satisfactoria; y 4,2 %, una calidad deficiente. Conclusiones : Las historias clínicas del centro de salud de Ica se encuentran en un estado por mejorar en un 53,8 %.
ABSTRACT Objective : The objective of this study was to assess the quality of dental medical record keeping at a health center in the city of Ica, Peru. Material and methods : We conducted a descriptive study using a quantitative, non-experimental, observational, cross-sectional, and retrospective approach. The sample comprised 212 medical records that were evaluated according to Health Technical Standard No. 029-MINSA/DIGEPRES-V.02. This standard, approved by Ministerial Resolution No. 502-2016/MINSA, allowed for the assessment of various aspects with corresponding scores. After tallying the scores obtained, we ranked the records accordingly. Results : The findings revealed that among the medical records at the health center in the city of Ica, 53.8 % demonstrated a need for improvement in quality, 42 % exhibited satisfactory quality, and 4.2 % displayed poor quality. Conclusions : The medical records at the Ica health center are in need of improvement for 53.8 % of cases.
RESUMO Objetivo : O objetivo do presente estudo foi determinar a qualidade do registro de prontuários odontológicos em um centro de saúde na cidade de Ica, Peru. Material e métodos : Foi realizado um estudo descritivo, quantitativo, não experimental, observacional, transversal e retrospectivo. A amostra consistiu em 212 registros médicos que foram avaliados usando a Norma Técnica de Saúde n.° 029-MINSA/DIGEPRES-V.02, aprovada pela Resolução Ministerial n.° 502-2016/MINSA, que permitiu a avaliação de diferentes aspectos com escores. Após somar as pontuações obtidas, elas foram classificadas. Resultados : Verificou-se que, entre os registros médicos do centro de saúde da cidade de Ica, 53,8% apresentavam uma qualidade a ser melhorada, 42% tinham uma qualidade satisfatória e 4,2% tinham uma qualidade ruim. Conclusões : Os registros médicos do centro de saúde de Ica estão em um estado de melhoria, com 53,8%.
ABSTRACT
Introduction: Keloids are one of the most aggressive spectrums of healing disorders. They have a unique pathophysiology and multiple specific genetic and cellular factors, which have not yet been fully elucidated. So far, literature reviews have found the influence of genetics, injury site, and ethnicity on the incidence and rate of recurrence. Furthermore, the need to associate an adjuvant method with surgical excision has already been verified, but the best therapy has yet to be defined. Method: A retrospective analysis of medical records was carried out to assess the profile of patients who underwent postoperative radiotherapy with an electron beam to treat keloids at the Hospital das Clínicas da Faculdade de Medicina de Botucatu between 2015 and 2019. Results: Data from 131 patients were evaluated, with 269 keloid scars treated. The average duration of treatment was 51 days, and the number of sessions was 17. White patients were predominant (78%) and women (70%), with surgical incision being the main cause of formation (49%) and ear the most identified location (33%). Women were more likely to complete the proposed treatment (p=0.04), while non-literates completed less than those who had at least completed primary or secondary education (p<0.0001). Conclusion: Postoperative radiotherapy for keloid scars is a well-established treatment in the literature and an important tool for plastic surgeons. Knowing the profile of patients who need this therapy is essential to create methods that improve adherence and results.
Introdução: Os queloides correspondem a um dos espectros mais agressivos dos distúrbios da cicatrização. Possuem fisiopatologia ímpar e múltiplos fatores genéticos e celulares específicos, ainda não totalmente elucidados. Até o momento, revisões literárias encontraram influência da genética, local da lesão e etnia sobre a incidência e taxa de recorrência. Ademais, já foi constatada a necessidade de associação de um método adjuvante com a excisão cirúrgica, mas ainda sem definição da melhor terapia. Método: Realizada uma análise retrospectiva de prontuários para avaliação do perfil dos pacientes submetidos a radioterapia pós-operatória com feixe de elétrons para o tratamento de queloides no Hospital das Clínicas da Faculdade de Medicina de Botucatu, entre 2015 e 2019. Resultados: Foram avaliados os dados de 131 pacientes, com um total de 269 cicatrizes queloideanas tratadas. A média da duração do tratamento foi de 51 dias e do número de sessões, de 17. Houve predominância de pacientes brancos (78%) e de mulheres (70%), sendo incisão cirúrgica a principal causa de formação (49%) e a orelha a localização mais identificada (33%). As mulheres tiveram mais chance de completar o tratamento proposto (p=0,04), enquanto os não alfabetizados completaram menos do que aqueles que tinham pelo menos ensino fundamental ou médio completo (p<0,0001). Conclusão: A radioterapia pós-operatória em cicatrizes queloideanas é um tratamento consagrado na literatura e uma importante ferramenta do cirurgião plástico. Conhecer o perfil dos pacientes que necessitam desta terapia é fundamental para criar métodos que melhorem a adesão e o resultado da mesma.
ABSTRACT
ABSTRACT BACKGROUND AND OBJECTIVES: Pain is a predominant symptom in the postoperative period and expected in any surgical service, being considered as a worldwide problem. Therefore, the aim of this study was to describe and analyze its epidemiological aspects, intensity, and predictors, for better management and predictability. METHODS: This is a quantitative, retrospective and cross-sectional observational study, carried out in a tertiary hospital at Londrina-PR, in which medical records of post-surgical patients who responded to pain scales during their stay in the post-anesthetic recovery room were analyzed. RESULTS: This study found that females are more likely to have postoperative pain and that younger patients are more susceptible, although not significantly. Mild pain predominated at rates greater than 60%, in which spinal blocks and gynecological/obstetric procedures were the most prevalent, in contrast to severe pain, which obtained higher percentages when general anesthesia and orthopedic surgeries were performed. In addition, an equation for predicting severe pain in the immediate postoperative period was obtained, based on the chosen anesthesia and the patient's age. CONCLUSION: Less intense postoperative pain was more prevalent than other intensities, with anesthesia and the type of surgery being possible predictive factors, even if the harbinger of its severity was based on age and the anesthetic method.
RESUMO JUSTIFICATIVA E OBJETIVOS: A dor é um sintoma predominante no pós-operatório e é esperada em qualquer serviço cirúrgico, sendo considerada um problema mundial. Portanto, o objetivo deste estudo foi descrever e analisar seus aspectos epidemiológicos, intensidade e preditores, tendo em vista um melhor manejo e previsibilidade. MÉTODOS: Estudo observacional quantitativo, retrospectivo e transversal, realizado em um hospital terciário no município de Londrina-PR, em que foram analisados prontuários de pacientes pós-cirúrgicos que responderam às escalas de dor durante permanência na sala de recuperação pós-anestésica. RESULTADOS: Esta pesquisa constatou que o sexo feminino possui maior tendência em ter dor pós-operatória e que pacientes mais jovens são os mais suscetíveis, apesar de não apresentarem grande significância. A dor leve predominou com taxas superiores a 60%, sendo que bloqueios espinhais e procedimentos ginecológicos/obstétricos foram os mais prevalentes, em contraste com a dor intensa, que obteve maiores percentuais quando realizadas anestesia geral e cirurgias ortopédicas. Além disso, obteve-se uma equação preditora de dores intensas no pós-operatório imediato, baseada no tipo de anestesia e na idade do paciente. CONCLUSÃO: A dor pós-operatória de menor intensidade foi mais prevalente que as outras intensidades, sendo a anestesia empregada e o tipo de cirurgia possíveis fatores preditores, mesmo que o prenúncio de sua severidade fosse baseado na idade e no método anestésico.
ABSTRACT
Introduction:Effective management of medical records is essential for delivering high‑quality treatment. The location, architecture, and personnel of a medical records department (MRD) can considerably impact its operational efficiency. This study seeks to examine hospital MRD and establishes whether its current configuration is suitable for effective medical record management. Materials and Methods: The descriptive method was utilized to evaluate the MRD of the hospital. The review analyzed the department’s physical layout, personnel, workload, training programs, and available equipment. The study also evaluated the influence of government and business restrictions on MRDs operations. Results: It was determined that the MRD of the hospital had an appropriate physical layout, with divisions positioned in optimal locations. The department’s personnel levels were adequate, with twenty employees managing the patient population’s workload. The analysis determined that the department required extra photocopiers and scanners to boost operational efficiency. In addition, the study underlined the significance of adhering to policies, protocols, and established processes in ensuring efficient workflow. Conclusion: The analysis concludes that the hospital MRD has an adequate physical layout, staffing levels, and task management. However, the present equipment could be enhanced to increase operational efficiency. The study also emphasizes the importance of adhering to policies, protocols, and written processes to ensure the department’s efficient workflow. The outcomes of this study may inform future decisions on MRD management in other health‑care organizations, especially those subject to comparable government and commercial regulations
ABSTRACT
Purpose: To describe the demographics, clinical characteristics, and presentation of solar retinopathy in patients who presented to a multi?tier ophthalmology hospital network in India. Methods: This cross?sectional, hospital?based study included 3,082,727 new patients presenting to the hospital between August 2010 and December 2021. Patients with a clinical diagnosis of solar retinopathy in at least one eye were included in the study. All the data was collected using an electronic medical record system. Results: Three hundred and forty?nine eyes of 253 (0.01%) patients were diagnosed with solar retinopathy and included in the study, and 157 patients (62.06%) had a unilateral affliction. Solar retinopathy was noted to be significantly more common in males (73.12%) and adults (98.81%). The most common age group at presentation was during the sixth decade of life with 56 (22.13%) patients. They were more commonly from the rural geography (41.9%). Among the 349 eyes, 275 (78.8%) eyes had mild or no visual impairment (<20/70), which was followed by moderate visual impairment (>20/70–20/200) found in 45 (12.89%) eyes. The most commonly associated ocular comorbidity was cataract in 48 (13.75%) eyes, followed by epiretinal membrane in 38 (10.89%) eyes. The most common retinal damage seen was interdigitation zone (IZ) disruption (38.68%), followed by inner segment–outer segment (IS–OS) disruption (33.52%). Foveal atrophy was seen in 105 (30.09%) eyes. Conclusion: Solar retinopathy is predominantly unilateral and is more common in males. It usually presents during the sixth decade of life and rarely causes significant visual impairment. The most common retinal damage seen was disruption of the outer retinal layers
ABSTRACT
Background & objectives: This study was aimed at estimating the proportion among sputum smear-positive tuberculosis (TB) patients diagnosed at a tertiary care centre in India, who did not undergo universal drug-susceptibility testing (UDST), assessing the sociodemographic and morbidity-related factors associated with it, ascertaining the reasons for not getting tested and estimating the proportion with any drug resistance (DR). Methods: TB Notification Register and TB Laboratory Register, maintained in Designated Microscopy Centre and Intermediate Research Laboratory, respectively were used to obtain the patient details and information regarding UDST and DR-TB status. Under UDST, the TB patients had undergone rapid molecular tests to check for any DR. TB patients who dropped out of this strategy (those who did not submit a sputum sample for DR testing even after being instructed) were telephonically contacted and asked regarding reasons for not getting themselves tested. Results: Of the 215 patients, 74 [34.4%, 95% confidence interval (CI): 28.1-41.2] did not undergo UDST. Of these 74 participants, 60 per cent reported the reason that they were not informed regarding the drug-susceptibility test. Among the 141 patients who underwent UDST, six (4.3%, 95% CI: 1.58-9.03) had DR. Non-UDST patients were significantly more in percentage among TB patients who were aged <30 years (adjusted prevalence ratio 2.36; 95% CI: 1.19-4.68) compared to >60 years. Interpretation & conclusions: The present findings point towards a need to sensitize healthcare workers and TB patients to improve UDST.