Medical Records: More Than the Health Insurance Portability and Accountability Act.

It is the responsibility of each organization, including private practice businesses, to maintain a comprehensive medical records retention policy. While registered dietitian nutritionists (RDNs) are qualified and competent business owners, navigating through the challenges of proper medical record management can be difficult without a sound policy. A comprehensive medical record retention policy consists of 4 major components: creation, utilization, maintenance, and destruction as well as a retention schedule. Successful implementation of a comprehensive medical record retention policy promotes positive clinician-patient interaction and avoidance of potential legal ramifications.

How Should Home-Based Maternal and Child Health Records Be Implemented? A Global Framework Analysis.

BACKGROUND: A home-based record (HBR) is a health document kept by the patient or their caregivers, rather than by the health care facility. HBRs are used in 163 countries, but they have not been implemented universally or consistently. Effective implementation maximizes both health impacts and cost-effectiveness. We sought to examine this research-to-practice gap and delineate the facilitators and barriers to the effective implementation and use of maternal and child health HBRs especially in low- and middle-income countries (LMICs). METHODS: Using a framework analysis approach, we created a framework of implementation categories in advance using subject expert inputs. We collected information through 2 streams. First, we screened 69 gray literature documents, of which 18 were included for analysis. Second, we conducted semi-structured interviews with 12 key informants, each of whom had extensive experience with HBR implementation. We abstracted the relevant data from the documents and interviews into an analytic matrix. The matrix was based on the initial framework and adjusted according to emergent categories from the data. RESULTS: We identified 8 contributors to successful HBR implementation. These include establishing high-level support from the government and ensuring clear communication between all ministries and nongovernmental organizations involved. Choice of appropriate contents within the record was noted as important for alignment with the health system and for end user acceptance, as were the design, its physical durability, and timely redesigns. Logistical considerations, such as covering costs sustainably and arranging printing and distribution, could be potential bottlenecks. Finally, end users' engagement with HBRs depended on how the record was initially introduced to them and how its importance was reinforced over time by those in leadership positions. CONCLUSIONS: This framework analysis is the first study to take a more comprehensive and broad approach to the HBR implementation process in LMICs. The findings provide guidance for policy makers, donors, and health care practitioners regarding best implementation practice and effective HBR use, as well as where further research is required.

Registro de pacientes y tratamientos de medicamentos hospitalarios en Cataluña: 10 años de datos clínicos / Registry of patients and treatments of hospital medicines in Spain: 10 years of clinical data

No disponible

Alive or dead: Validity of the Social Security Administration Death Master File after 2011.

OBJECTIVE: To determine the reliability of the Social Security Death Master File (DMF) after the November 2011 changes limiting the inclusion of state records. DATA SOURCES: Secondary data from the DMF, New York State (NYS) and New Jersey (NJ) Vital Statistics (VS), and institutional data warehouse. STUDY DESIGN: Retrospective study. Two cohorts: discharge date before November 1, 2011, (pre-2011) or after (post-2011). Death in-hospital used as gold standard. NYS VS used for out-of-hospital death. Sensitivity, specificity, Cohen's Kappa, and 1-year survival calculated. DATA COLLECTION METHODS: Patients matched to DMF using Social Security Number, or date of birth and Soundex algorithm. Patients matched to NY and NJ VS using probabilistic linking. PRINCIPAL FINDINGS: 97 069 patients January 2007-March 2016: 39 075 pre-2011; 57 994 post-2011. 3777 (3.9 percent) died in-hospital. DMF sensitivity for in-hospital death 88.9 percent (κ = 0.93) pre-2011 vs 14.8 percent (κ = 0.25) post-2011. DMF sensitivity for NY deaths 74.6 percent (κ = 0.71) pre-2011 vs 26.6 percent (κ = 0.33) post-2011. DMF sensitivity for NJ deaths 62.6 percent (κ = 0.64) pre-2011 vs 10.8 percent (κ = 0.15) post-2011. DMF sensitivity for out-of-hospital death 71.4 percent pre-2011 (κ = 0.58) vs 28.9 percent post-2011 (κ = 0.34). Post-2011, 1-year survival using DMF data was overestimated at 95.8 percent, vs 86.1 percent using NYS VS. CONCLUSIONS: The DMF is no longer a reliable source of death data. Researchers using the DMF may underestimate mortality.

Analysis of the behavior change mechanism of township hospital health workers in Hubei Province, China: A cross-sectional study.

This study aims to analyze the behavior changes of health workers in township hospitals by exploring their individual service, health information utilization, and health information exchange before and after intervention.A cross-sectional survey was conducted from September, 2016 to December, 2016 in Qianjiang city, Hubei Province, China. A total of 432 township hospital health workers were investigated from 12 township hospitals. t test and chi-square test were adopted in the difference analysis to compare the behavior changes and factors of the control and intervention groups before and after intervention. t test and U test were used to analyze the behaviors and the key impact factors of health workers in township hospitals. The hypothesis test of the behavior changes in the township hospitals were analyzed using the partial least squares (PLS) method.No significant difference was observed between the control and intervention groups of health workers in township hospitals. Significant differences were observed in the behavior attitude (BA), perceived behavior control (PBC), behavior intention (BI), and behaviors of information utilization and exchange in the intervention group. A significant difference was observed in the indicators of subjective norm (SN), BI, and behaviors with respect to information exchange. A large increment was observed in the intervention group. Based on results of PLS, the individual service, health information utilization, and health information exchange established relationships with BA, SN, PBC, and BI to a certain degree.A cause and effect relationship can be observed among BA, SN, PBC, BI, and behaviors of health workers in the township hospitals. BI can promote behavior changes among township hospital health workers. Moreover, different behaviors are demonstrated by different people because of BA, SN, PBC, and BI. The results of this study can contribute to improving the feasibility, pertinence, and effects of health service, and can serve as the guide in understanding health workers' behaviors.

Análisis de los ingresos hospitalarios por insuficiencia cardiaca en registros sanitarios de diferentes comunidades autónomas. Respuesta / Analysis of hospitalization trends for heart failure in the health registries of different autonomous communities. Response

No disponible

Anesthesia Information Management Systems.

Anesthesia information management systems (AIMS) have evolved from simple, automated intraoperative record keepers in a select few institutions to widely adopted, sophisticated hardware and software solutions that are integrated into a hospital's electronic health record system and used to manage and document a patient's entire perioperative experience. AIMS implementations have resulted in numerous billing, research, and clinical benefits, yet there remain challenges and areas of potential improvement to AIMS utilization. This article provides an overview of the history of AIMS, the components and features of AIMS, and the benefits and challenges associated with implementing and using AIMS. As AIMS continue to proliferate and data are increasingly shared across multi-institutional collaborations, visual analytics and advanced analytics techniques such as machine learning may be applied to AIMS data to reap even more benefits.

¿Es necesario un registro nacional de dislipemias? / Is a national registry of dyslipidaemia necessary?

No disponible

Creating a National Provider Identifier (NPI) to Unique Physician Identification Number (UPIN) Crosswalk for Medicare Data.

INTRODUCTION: Many health services researchers are interested in assessing long term, individual physician treatment patterns, particularly for cancer care. In 2007, Medicare changed the physician identifier used on billed services from the Unique Physician Identification Number (UPIN) to the National Provider Identifier (NPI), precluding the ability to use Medicare claims data to evaluate individual physician treatment patterns across this transition period. METHODS: Using the 2007-2008 carrier (physician) claims from the linked Surveillance, Epidemiology and End Results (SEER) cancer registry-Medicare data and Medicare's NPI and UPIN Directories, we created a crosswalk that paired physician NPIs included in SEER-Medicare data with UPINs. We evaluated the ability to identify an NPI-UPIN match by physician sex and specialty. RESULTS: We identified 470,313 unique NPIs in the 2007-2008 SEER-Medicare carrier claims and found a UPIN match for 90.1% of these NPIs (n=423,842) based on 3 approaches: (1) NPI and UPIN coreported on the SEER-Medicare claims; (2) UPINs reported on the NPI Directory; or (3) a name match between the NPI and UPIN Directories. A total of 46.6% (n=219,315) of NPIs matched to the same UPIN across all 3 approaches, 34.1% (n=160,277) agreed across 2 approaches, and 9.4% (n=44,250) had a match identified by 1 approach only. NPIs were paired to UPINs less frequently for women and primary care physicians compared with other specialists. DISCUSSION: National Cancer Institute has created a crosswalk resource available to researchers that links NPIs and UPINs based on the SEER-Medicare data. In addition, the documented process could be used to create other NPI-UPIN crosswalks using data beyond SEER-Medicare.

Respuesta al escrito de Chero-Farro et al / Repply to the letter of Cherro-Farro et al

No disponible

Medico-Legal Considerations in Providing Emergency Dental Care in Practice.

The unpredictability of unscheduled emergency dental care carries its own clinical, communication and management challenges with associated medico-legal risks. Providing emergency dental treatment for unfamiliar patients in an unfamiliar environment amplifies the hidden pitfalls which failure to avoid can create potentially damaging critical incidents in a practitioner's professional life. These are preferably avoided through consistent attention to best practice and risk management. Day to day processes, such as excellent record-keeping, valid consent and effective communication are under the spotlight in the event that a patient complains, raises a concern with a regulator or seeks compensation following alleged negligent care. This paper aims to highlight the dento-legal pitfalls that may be pertinent in such a challenging situation.

Automated anesthesia carts reduce drug recording errors in medication administrations - A single center study in the largest tertiary referral hospital in China.

AIM: To clinically evaluate a type of patented automated anesthesia cart in medication administrations in anesthesia. MATERIALS AND METHODS: This was a prospectively randomized open label clinical trial. In 10 designated operating suits in the First Affiliated Hospital of Zhengzhou University, in China. 1066 cases originated from 10,812 medication administrations in anesthesia were randomized. 78 registered anesthesiologists managed the medication. The patients received medication administrations in anesthesia with either an automated or a conventional manual cart. American Society of Anesthesiologists (ASA) score, sex, duration of anesthesia and surgical specialty, errors in administration of medications (incorrect medication given (substitution), medication not given (omission) and drug recordings errors"), compliance and satisfaction were recorded. RESULTS: The total error rate was 7.3% with the automated anesthesia carts (1 in 14 administrations) and 11.9% with conventional manual carts (1 in 8 administrations). Automated anesthesia carts significantly reduced the drug recording error rate compared to conventional manual carts (P<0.01). However, no significant difference of substitution or errors omission errors was found between groups of automated anesthesia carts and conventional manual carts. The anesthesiologists' compliance with the automated anesthesia carts was unsatisfactory, and all the errors in medication recordings with the automated anesthesia carts were due to the incorrect use of the carts. Most of the participating anesthesiologists preferred the automated anesthesia carts (P<0.05). CONCLUSIONS: The utilization of automated anesthesia carts reduced the drug recording errors in medication administrations of anesthesia.

Registro nacional de implantes mamarios: la experiencia española / No disponible

No disponible

Determinar el riesgo médico-legal de la historia clínica mediante la aplicación de un Score / DETERMINATION OF THE THE MEDICO-LEGAL RISK IN THE CLINICAL HISTORY WITH THE APPLICATION OF A SCORE

El objetivo de este trabajo es identificar aquellas variables previamente definidas -indicios que podrían ser elevados al rango de prueba- en las propias historias clínicas confeccionadas, y establecer preventivamente un score de riesgo médicolegal, por lo que un profesional o una institución entonces, podrán así determinar y categorizar entonces el riesgo médicolegal en el propio documento médico

The objective of this paper is to identify some previously defined variables ­ legal indications that could be raised to the legal proof ­ at the medical reports themselves, and to establish preventively a medical legal risk score, so that a professional or an Institution can then determine and categorize the medical-legal risk in the medical document itself

Historia clínica como herramienta para mejora del proceso de atención / Clinical records as a tool for enhancing medical care

No disponible

Transfer of DNR orders to the ED from extended care facilities.

PURPOSE/OBJECTIVE: With an elderly and chronically ill patient population visiting the emergency department, it is important to know patients' wishes regarding care preferences and advanced directives. Ohio law states DNR orders must be transported with the patient when they leave an extended care facility (ECF). We reviewed the charts of ECF patients to evaluate which patients presenting to the ED had their DNR status recognized by the physician and DNR orders that were made during their hospital stay. METHODS: We prospectively enrolled patients presenting from ECFs to the ED, blinding the treating team to the purpose. We did a chart review for the presence of a DNR form, demographic data and acknowledgement of the DNR forms. RESULTS: Fifty patients were enrolled in this study. The mean age was 77.6years and 56% were female. Twenty-eight percent had a DNR order transported to the ED, but 68% had a DNR preference noted in their ECF notes. Registration only noted an advanced directive on 32% of patients (p=0.09). Eighteen percent had a DNR noted by the ED physician (p=0.42). Sixteen percent of patients had a DNR order written by an ED physician while 28% had a DNR order written by a non-ED physician during their inpatient evaluation. Thirty percent had a palliative care consult while in the hospital, but there was no significant association between DNR from the ECF and these consults. CONCLUSIONS: Hospital staff did a poor job of noting DNR preferences and ECFs were inconsistent with sending Ohio DNR forms.

Resultados clínicos del uso de los nuevos antiagregantes en la vida real / New antiplatelet agents: real-world clinical findings

Los hallazgos cada vez más numerosos sobre el uso de tratamiento antiagregante plaquetario doble (TAPD) con los nuevos antiagregantes en la vida real, muchos procedentes de centros españoles (EPICOR, ARIAM o ACHILLES), parecen confirmar los datos que presentaron los grandes estudios fundamentales. Generalmente, se acompañan de un mayor beneficio en cuanto a eventos isquémicos y mortalidad, pero suelen ir acompañados de mayores tasas hemorrágicas. La utilización de dichos antiagregantes es progresivamente mayor en comparación con el TAPD basado en clopidogrel. Por otro lado, el uso prolongado de TAPD es una práctica común en el mundo real, variable entre los diferentes países estudiados, y sus resultados dependen en gran medida del perfil de riesgo o el balance isquémico-hemorrágico de los pacientes incluidos en cada serie (AU)

The increasing amount of real-world data available on the use of double antiplatelet therapy with new antiplatelet agents, including data from Spanish centers (e.g. the EPICOR, ARIAM and ACHILLES studies), appear to confirm the findings of large pivotal trials. Generally, use of these agents results in substantial clinical benefits, including fewer ischemic events and lower mortality, but there is usually an associated increase risk of hemorrhage. The uptake of these new antiplatelet agents continues to grow relative to that of clopidogrel-based double antiplatelet therapy. In addition, prolonged use of dual antiplatelet therapy is common practice in the real world, with substantial variations between countries. Therapeutic outcomes depend to a large extent on the risk profiles of, and the balance between ischemic and hemorrhagic risk in, patients included in individual case series (AU)