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2.
Euro Surveill ; 25(42)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33094715

RESUMO

An outbreak of 59 cases of coronavirus disease (COVID-19) originated with 13 cases linked by a 7 h, 17% occupancy flight into Ireland, summer 2020. The flight-associated attack rate was 9.8-17.8%. Spread to 46 non-flight cases occurred country-wide. Asymptomatic/pre-symptomatic transmission in-flight from a point source is implicated by 99% homology across the virus genome in five cases travelling from three different continents. Restriction of movement on arrival and robust contact tracing can limit propagation post-flight.


Assuntos
Viagem Aérea , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Doença Relacionada a Viagens , Doenças Assintomáticas , Betacoronavirus/genética , Busca de Comunicante , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Surtos de Doenças , Exposição Ambiental , Características da Família , Controle de Formulários e Registros , Genoma Viral , Hospitalização , Humanos , Controle de Infecções/métodos , Irlanda/epidemiologia , Nasofaringe/virologia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , RNA Viral/genética , Estações do Ano , Homologia de Sequência do Ácido Nucleico , Fatores de Tempo , Sequenciamento Completo do Genoma
3.
S Afr Med J ; 110(7): 605-606, 2020 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-32880330

RESUMO

In the South African public healthcare sector, patient medical records are still written on paper and stored in filing rooms. There has been an attempt to move towards a paperless electronic system in many public healthcare facilities, but owing to lack of funding, this has been a challenge to achieve. During the current COVID-19 pandemic, the virus could be transmitted through the physical manipulation of patient records by various categories of staff who handle the records with or without gloves for protection. We discuss a digital option that has been partially used at Tygerberg Hospital (TBH), Cape Town, to avoid SARS-CoV-2 patient hard-copy record manipulation. It includes assignment of a QR code to every patient admitted as a person under investigation or confirmed COVID-19 case. The QR code is synced to one of the many free online medical notes smartphone applications (apps), which are password-protected with patient information privacy regulations (Trello is used at TBH), for daily medical notes review and editing. Upon discharge, all notes made during the patient's hospital stay, together with the discharge summary, are printed to generate a hard copy of notes for filing to avoid violation of the current national and provincial patient records policy. Doing this means that a patient will have a virtual online file through the designated app until discharge, when a physical file will be made for storage and safekeeping. It will keep physical manipulation of patient records to the minimum, and potentially assist in reducing transmission of the SARS-CoV-2 virus among healthcare workers.


Assuntos
Infecções por Coronavirus/prevenção & controle , Transmissão de Doença Infecciosa/prevenção & controle , Registros Eletrônicos de Saúde/economia , Controle de Infecções/métodos , Saúde do Trabalhador , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Infecções por Coronavirus/epidemiologia , Custos e Análise de Custo , Países em Desenvolvimento , Registros Eletrônicos de Saúde/organização & administração , Feminino , Controle de Formulários e Registros , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Registros Médicos/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , África do Sul
4.
Tex Med ; 116(8): 43-44, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866277

RESUMO

First, the bad news: Physicians need to take some serious time between now and Jan 1, 2021, to study changes that are coming to Medicare outpatient evaluation and management (E&M) codes - changes most private insurers likely will follow. Now the good news: The changes should reduce the amount of documentation needed with each patient.


Assuntos
Medicare/normas , Pacientes Ambulatoriais , Padrões de Prática Médica/economia , Avaliação de Sintomas/normas , Documentação , Controle de Formulários e Registros , Humanos , Seguro Saúde , Visita a Consultório Médico/economia , Reembolso de Incentivo , Estados Unidos
5.
Rev. bioét. (Impr.) ; 28(3): 486-492, jul.-set. 2020. tab
Artigo em Português | LILACS | ID: biblio-1137117

RESUMO

Resumo Este estudo objetiva analisar prontuários odontológicos utilizados na graduação em odontologia no Brasil, considerando sua adequação à legislação e diretrizes éticas em vigor. Os coordenadores dos 220 cursos cadastrados na página eletrônica do Conselho Federal de Odontologia foram convidados, e 96 deles aceitaram participar da pesquisa. Para coletar e analisar os dados, utilizou-se roteiro estruturado com questões éticas e legais. Do total da amostra, 53,2% dos prontuários apresentaram todos os documentos mínimos necessários, mas nenhum cumpriu todos os requisitos de identificação do paciente, anamnese, termo de consentimento livre e esclarecido e odontograma. Além disso, 17,8% cumpriram todos os itens relativos a planejamento e 61,5% atenderam às exigências de autorização para uso de dados e imagens. Conclui-se que os prontuários não se adequam à legislação atual, devendo ser revistos a fim de melhorar a qualidade da informação e evitar problemas administrativos, morais e jurídicos.


Abstract This study analyzes the dental records used in the Brazilian dentistry courses, considering their suitability regarding the ethical guidelines of the legislation in force in the country. All the coordinators of the 220 graduation courses registered on the Federal Council of Dentistry's website were invited, and 96 (43.6%) accepted to participate in our research. For the collection and analysis of data, we used a structured questionnaire with ethical and legislative questions. Of the total sample, 53.2% presented all the necessary minimum documents, but none of them met all the requirements of patient identification, anamnesis, informed consent form, and odontograms. Moreover, 17.8% fulfilled all the items for planning, and 61.5% had the authorization for the use of data and images. We concluded that these records do not conform to the current legislation and must be updated in order to obtain an improvement in the quality of the information, avoiding administrative, moral and legal problems.


Resumen Este estudio objetivó analizar los registros odontológicos utilizados en cursos de grado en odontología en Brasil, verificando su adecuación a la legislación y directrices en vigor. Se invitaron a todos los coordinadores de 220 cursos registrados en la página electrónica del Consejo Federal de Odontología, y 96 aceptaron participar. Para la recolección y análisis de datos, se utilizó un guion estructurado abordando cuestiones éticas y de legislación. Del total, el 53,2% de los registros clínicos presentaron los documentos mínimos requeridos; ninguno cumplió todos los requisitos de identificación del paciente, anamnesis, formulario de consentimiento informado y odontograma; el 17,8% cumplió todos los ítems de planificación; y el 61,5% atendió a los ítems de autorización del uso de datos y imágenes. Se concluye que estos registros no se adecuan a la legislación vigente y deben ser actualizados para mejorar la calidad de las informaciones, evitando problemas de orden administrativo, moral y legal.


Assuntos
Estudantes de Odontologia , Brasil , Responsabilidade Legal , Odontologia Legal , Controle de Formulários e Registros , Legislação como Assunto
6.
Artigo em Inglês | MEDLINE | ID: mdl-32751668

RESUMO

We examined parent views of health professionals and satisfaction toward use of a child health home-based record and the influence on parent engagement with the record. A cross-sectional survey of 202 parents was conducted across New South Wales (NSW), Australia. Bivariate and multivariate logistic regressions were conducted to identify predictors of parent engagement with the record book using odds ratio (OR) at 95% confidence interval (CI) and 0.05 significance level. Parents reported utilizing the record book regularly for routine health checks (63.4%), reading the record (37.2%), and writing information (40.1%). The majority of parents (91.6%) were satisfied with the record. Parents perceived nurses/midwives as most likely to use/refer to the record (59.4%) compared to pediatricians (34.1%), general practitioners (GP) (33.7%), or other professionals (7.9%). Parents were less likely to read the record book if they perceived the GP to have a lower commitment (Adjusted OR = 0.636, 95% CI 0.429-0.942). Parents who perceived nurses/midwives' willingness to use/refer to the record were more likely to take the record book for routine checks (Adjusted OR = 0.728, 95% CI 0.536-0.989). Both parent perceived professionals' attitude and satisfaction significantly influenced information input in the home-based record. The results indicate that improvements in parent engagement with a child health home-based record is strongly associated with health professionals' commitment to use/refer to the record during consultations/checks.


Assuntos
Saúde da Criança , Controle de Formulários e Registros , Satisfação Pessoal , Austrália , Criança , Estudos Transversais , Feminino , Humanos , Masculino , New South Wales , Pais , Gravidez , Inquéritos e Questionários
7.
PLoS One ; 15(8): e0235826, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32760142

RESUMO

BACKGROUND: Thrombophilia-screen tests are specialised haemostasis tests that are affected by numerous unique patient variables including the presence of acute thrombosis, the concomitant use of medication and patient demographics. Complete information on the request form is therefore crucial for the haematological pathologist to make patient-specific interpretation of patients' results. OBJECTIVES: To assess the completeness of thrombophilia-screen test request forms and determine the impact of provision of incomplete information, on the interpretive comments generated by reporting haematological pathologists. To assess the impact of an educational session given to clinicians on the importance of providing all the relevant information on the request forms. METHOD: Two retrospective audits, each covering 3 months, were performed to evaluate the completeness of demographic and clinical information on thrombophilia-screen request forms and its impact on the quality of the interpretive comments before and after an educational intervention. RESULTS: One hundred and seventy-one request forms were included in the first audit and 146 in the second audit. The first audit revealed that all 171 thrombophilia-screen request forms had complete patient demographic information but none had clinical information. Haematological pathologists only made generic comments which could not be applied to a specific patient. The second audit, conducted after a physician educational session, did not reveal any improvement in the clinical information provision by the test-ordering physicians. This was reportedly due to the lack of space on the request form. The interpretive comments therefore remained generic and not patient-specific. CONCLUSION: Physicians' failure to provide relevant clinical information made it impossible for pathologists to make patient-specific interpretation of the results. A single physician education session did not change the practice, reportedly due to the inappropriate design of the test request form. Further studies are required to investigate the impact of an improved request form and the planned electronic test requesting.


Assuntos
Educação Médica Continuada , Programas de Rastreamento/normas , Registros Médicos/normas , Médicos/normas , Trombofilia/diagnóstico , Controle de Formulários e Registros/estatística & dados numéricos , Humanos , Programas de Rastreamento/estatística & dados numéricos , Auditoria Médica/estatística & dados numéricos , Registros Médicos/estatística & dados numéricos , Médicos/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , África do Sul
9.
Notas enferm. (Córdoba) ; 20(35): 21-29, jun. 2020. graf.
Artigo em Espanhol | LILACS, BDENF - Enfermagem, BINACIS, UNISALUD | ID: biblio-1119038

RESUMO

Los registros de enfermería son un fiel reflejo de las actividades que el profesional de enfermería realiza de los cuidados que se brindan y de cuanta dedicación y empeño otorga en favor de lograr el bienestar del paciente. En ellos se debe dejar constancia no solo de los signos vitales, sino también dejar reflejada la visión holística que el enfermero aplica a cada uno de sus pacientes como seres únicos. Se realizó un estudio observacional, descriptivo, evaluativo y retrospectivo, constituido por los registros realizados por el personal de Enfermería en las historias clínicas de los pacientes internados en el internado general del Sanatorio Allende Cerro en Agosto/septiembre de 2019. La selección de la unidad de análisis fue por muestreo aleatorio simple. Se realizó auditoría de los registros de Enfermería de 13 historias clínicas desde el momento de ingreso a la institución hasta el egreso del mismo, constituyendo un total de 208 registros de Enfermería. Esta investigación determinó que 10 de 15 indicadores que se propusieron para valorar la calidad de nuestros registros fueron clasificados como escasamente adecuado, lo que refleja la necesidad de centrar la atención en mejorar la calidad de nuestros registros de enfermería, ya que estos son documentos sobre actos y conductas profesionales que conllevan a responsabilidades de índole profesional y legal[AU]


Assuntos
Controle de Qualidade , Registros de Enfermagem , Auditoria de Enfermagem , Controle de Formulários e Registros
10.
Notas enferm. (Córdoba) ; 20(35): 13-20, jun. 2020. graf.
Artigo em Espanhol | LILACS, BDENF - Enfermagem, BINACIS, UNISALUD | ID: biblio-1119033

RESUMO

La Historia Clínica constituye una de las fuentes de información sobre la asistencia sanitaria que prestan los profesionales de enfermería a través del registro, como una herramienta para el cuidado diario de enfermería, que permite dejar sellado el accionar realizado. Todo ello conlleva una responsabilidad a nivel profesional y legal, que precisa de una práctica basada en el rigor científico, ético y legal. El objetivo fue evaluar la implementación del registro de cuidados relacionados a la seguridad emocional en pacientes internados en el servicio de Unidad Coronaria. Se realizó una investigación evaluativa, utilizando los registros electrónicos de enfermería de las historias clínicas. Las dimensiones estudiadas fueron siete: como la Dimensión Vincular, Ambiental, experticia técnica, Comunicacional, Corporal, Asistencia específica y Afectiva. Resultados: no son registrados en todos los informes los cuidados de seguridad emocional, el turno noche presenta mayor cantidad de registros de cuidados emocionales, en el segundo lugar turno mañana y menor porcentaje turno tarde. La dimensión ambiental fue la mayor registrada y la menos registrada fue la dimensión de experticia. Conclusiones: Se recomienda continuar con las capacitaciones para concientizar sobre la importancia de registrar ya que es la evidencia de los cuidados que se proporcionan. Estos registros demuestran el rol autónomo de enfermería, y la valoración y cuidado de los aspectos emocionales de cada uno de los pacientes asistidos[AU]


Assuntos
Humanos , Registros de Enfermagem , Estudo de Avaliação , Segurança do Paciente , Enfermagem Cardiovascular , Controle de Formulários e Registros
11.
Rev. clín. esp. (Ed. impr.) ; 220(4): 215-227, mayo 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-194885

RESUMO

INTRODUCCIÓN: El certificado médico de defunción es un documento con una doble función: registro oficial del fallecimiento de una persona y análisis estadístico de las causas de muerte de la población. La cumplimentación de este documento en la práctica clínica genera grandes conflictos. OBJETIVOS: Analizar la cumplimentación y detectar los principales errores que existen al rellenar estos documentos. Se procedió a la comparación de las variables más importantes entre los diferentes tipos de documentos analizados. MATERIAL Y MÉTODOS: Estudio transversal descriptivo. Se analizaron 513 certificados del municipio de Madrid. El análisis incluía documentos oficiales, nuevos y antiguos, y de los hospitales. RESULTADOS: Como principal hallazgo destacó que 316 documentos empleaban el término «parada cardiorrespiratoria» como causa inmediata de muerte. En otros 98 casos se emplearon otras causas inmediatas mal definidas. También se pudo concluir que los documentos de los hospitales no siempre tienen los apartados requeridos para que el certificado haga su función legal. En los certificados de la Organización Médica Colegial existe una peor cumplimentación en el documento actual porque el propio documento dificulta que se rellene adecuadamente y precisa una mejor formación del médico para rellenarlo. CONCLUSIONES: Se proponen posibles mejoras en el propio documento oficial para que se consideren las exigencias legales, se facilite su cumplimentación y cumpla su función. También se proponen recomendaciones para los hospitales que tengan su propio documento y sugerencias de mejora de la cumplimentación


BACKGROUND: The medical certificate of cause of death is a dual-purpose document: an official registration of an individual's death and a statistical analysis of the populational causes of death. However, the completion of this document in clinical practice creates significant conflicts. OBJECTIVES: To analyse the completion and detect the main errors that occur when filling in these documents. We then compared the most important variables between the various types of documents analysed. MATERIAL AND METHODS: We conducted a descriptive cross-sectional study that analysed 513 certificates in the municipality of Madrid, Spain. The analysis included official documents (new and old versions) and hospital documents. RESULTS: The study's main finding was that 316 documents employed the term "cardiopulmonary arrest" as the immediate cause of death. In 98 other cases, other poorly defined immediate causes were listed. We were able to conclude that the hospital documents do not always have the required sections for the certificate to be legally functional. In the Professional Medical Association certificates, there is poorer completion of the current document because the document itself hinders its appropriate completion and requires better physician training to complete. CONCLUSIONS: We propose possible improvements to the official document so that it meets the legal requirements, facilitates its completion and fulfils its function. We also offer recommendations for hospitals that have their own document and suggestions for improving its completion


Assuntos
Humanos , Causas de Morte , Atestado de Óbito , Estudos Transversais , Erros de Diagnóstico , Epidemiologia Descritiva , Médicos , Médicos Legistas , Controle de Formulários e Registros/normas , Espanha/epidemiologia
13.
Scand J Trauma Resusc Emerg Med ; 28(1): 25, 2020 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-32245496

RESUMO

BACKGROUND: Physician-staffed emergency medical services (p-EMS) are resource demanding, and research is needed to evaluate any potential effects of p-EMS. Templates, designed through expert agreement, are valuable and feasible, but they need to be updated on a regular basis due to developments in available equipment and treatment options. In 2011, a consensus-based template documenting and reporting data in p-EMS was published. We aimed to revise and update the template for documenting and reporting in p-EMS. METHODS: A Delphi method was applied to achieve a consensus from a panel of selected European experts. The experts were blinded to each other until a consensus was reached, and all responses were anonymized. The experts were asked to propose variables within five predefined sections. There was also an optional sixth section for variables that did not fit into the pre-defined sections. Experts were asked to review and rate all variables from 1 (totally disagree) to 5 (totally agree) based on relevance, and consensus was defined as variables rated ≥4 by more than 70% of the experts. RESULTS: Eleven experts participated. The experts generated 194 unique variables in the first round. After five rounds, a consensus was reached. The updated dataset was an expanded version of the original dataset and the template was expanded from 45 to 73 main variables. The experts approved the final version of the template. CONCLUSIONS: Using a Delphi method, we have updated the template for documenting and reporting in p-EMS. We recommend implementing the dataset for standard reporting in p-EMS.


Assuntos
Documentação , Serviços Médicos de Emergência , Atitude do Pessoal de Saúde , Consenso , Técnica Delfos , Controle de Formulários e Registros , Humanos , Registros Médicos , Projetos de Pesquisa
14.
Ciênc. Saúde Colet ; 25(4): 1305-1312, abr. 2020. tab
Artigo em Português | LILACS | ID: biblio-1089510

RESUMO

Resumo Analisaram-se os registros eletrônicos da atenção primária em saúde na cidade do Rio de Janeiro para duas doenças crônicas: hipertensão e diabetes, em um estudo de base populacional, com desenho epidemiológico transversal que considerou a população carioca que possuía "Equipes de Saúde da Família". O cálculo da taxa de prevalência foi estratificado por sexo e faixa etária, e a condição da doença foi mensurada pelos médicos de família nas consultas realizadas por estes, computando-se a CID-10. Excetuando-se as duas últimas faixas etárias (75 a 79 anos e 80 anos e mais), em que parece haver subregistro dos casos diagnosticados, observou-se uma associação positiva entre as taxas de prevalência e a faixa etária, em ambos os sexos. A geração de informações estatísticas objetivas e com confiabilidade é fundamental para a gestão no nível local, permitindo avaliar a dinâmica demográfica e as particularidades de cada território, e auxiliando no planejamento e monitoramento da qualidade dos registros dos cariocas cadastrados em cada unidade de saúde da família. Para isso, a gestão regular de registros duplicados nas listas de usuários cadastrados é fundamental para minimizar o sobreregistro de casos clínicos apontados nos prontuários eletrônicos.


Abstract Primary health care electronic medical records were analyzedin Rio de Janeiro for two chronic diseases, namely, hypertension and diabetes, in a population-based study with a cross-sectional epidemiological design that considered the Rio de Janeiro population enrolled in Family Health Teams. Calculation of the prevalence rate was stratified by gender and age group, and the condition of the disease was measured by family doctors in their visits using the ICD-10.Except for the last two age groups (75-79 years and 80 years and over), with apparent under-registration of the diagnosed cases, a positive association was found between prevalence rates and age in both genders. The generation of objective and reliable statistical information is fundamental for local management, allowing the evaluation of demographic dynamics and the peculiarities of each territory, and assisting in the planning and monitoring of the quality of Rio de Janeiro people's records registered in each family health unit. Thus, the regular management of duplicate records in the registered user roster is essential to minimize the over-registration of clinical cases reported in the electronic medical records.


Assuntos
Humanos , Masculino , Feminino , Adulto , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Atenção Primária à Saúde , Diabetes Mellitus/epidemiologia , Registros Eletrônicos de Saúde , Hipertensão/epidemiologia , Brasil/epidemiologia , Estudos Epidemiológicos , Prevalência , Estudos Transversais , Distribuição por Sexo , Distribuição por Idade , Controle de Formulários e Registros/métodos , Pessoa de Meia-Idade
15.
Ciênc. Saúde Colet ; 25(4): 1241-1250, abr. 2020. tab, graf
Artigo em Português | LILACS | ID: biblio-1089522

RESUMO

Resumo A Classificação Internacional de Atenção Primária-2 (CIAP-2) é fruto de quarenta anos de desenvolvimento contínuo. Tem origem na segunda metade do século XX, a partir da inquietação de médicos gerais com a necessidade de se registrar e codificar dados especificamente relacionados à atenção primária, tanto nos motivos de consulta quanto nos procedimentos e nas condições ou diagnósticos. A Organização Mundial de Saúde chancelou a classificação bem como o seu comitê desenvolvedor após o encontro de Alma-Ata, pois também identificou necessidades específicas. Hoje há essencialmente duas formas de uso na coleta de informações: por encontro ou por episódio de cuidado. A segunda forma é mais complexa e controversa. Recentemente foi lançada a décima primeira versão da Classificação Internacional de Doenças, enquanto que a CIAP-3 esta sendo desenvolvida. Não há como prever como vão interagir com as novas tecnologias, as classificações e os organismos internacionais. O protagonismo dos profissionais da ponta e dos pacientes tem potencial de definir a direção.


Abstract The International Classification of Primary Care-2 (ICPC-2) is the result of forty years of continuous development. It originates in the second half of the twentieth century after the concern of general practitioners about the need to record and encode data specifically related to primary care, both in the reasons for encounter and procedures and conditions or diagnoses. The World Health Organization endorsed the classification, as did the developer committee after the Alma Ata meeting, since it also identified specific needs. Two forms of use are employed now in gathering information: by encounter or by an episode of care. The latter is more complex and controversial. Recently, an eleventh version of the International Classification of Diseases has been released, and the third edition of ICPC is being developed. One cannot predict how new technologies, classifications, and international organizations will interact. The role of front line health professionals and patients will define the course.


Assuntos
Humanos , Atenção Primária à Saúde , Classificação Internacional de Doenças , Cuidado Periódico , Medicina de Família e Comunidade , Diagnóstico , Medicina Geral , Codificação Clínica , Controle de Formulários e Registros , Terminologia como Assunto
17.
Med. leg. Costa Rica ; 37(1): 179-191, ene.-mar. 2020. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1098385

RESUMO

Resumen Introducción: El objetivo de la investigación fue establecer cuál es la simbología utilizada por los profesionales en odontología para documentar los hallazgos odontológicos más comunes en sus expedientes; con la finalidad de incluirla en un formato único odontológico estandarizado con fines de identificación en Costa Rica. Materiales y métodos: Mediante un cuestionario se identificó y comparó la simbología utilizada por profesionales en odontología generales y especialistas para registrar los hallazgos odontológicos en sus expedientes. Se realizó una fase piloto con 8 cuestionarios y posterior a las correcciones se aplicó a una muestra de 49 odontólogos que incluyó a profesionales en odontología generales y de todas las especialidades. Las técnicas estadísticas utilizadas para el análisis de la información recolectada en las encuestas son las distribuciones de frecuencia, cruce de variables, comparación de medias con base en el análisis de variancia. El nivel mínimo de confianza para las comparaciones fue del 95%. El procesamiento estadístico de los datos se diseñó una base de datos creada en EPI-INFO 6.4, el procesamiento estadístico de los datos se realizó en SPSS versión 13.0 y en Excel. Resultados: De los 49 participantes, 56% fueron hombres y 44% mujeres. La edad varía entre 25 y 65 años; la edad promedio fue de 44,5 años (IC 95%: 41,7 - 47,3) y una edad mediana [1] de 43 años, la cual no tuvo diferencia estadísticamente significativa (p = 0,552) entre la edad promedio entre los hombres y mujeres. El 70% de los odontólogos usan expediente físico, mientras que sólo un 17% usan expediente digital, y el 13% usan ambos; en el expediente digital es en el que se presenta la mayoría de problemas con un 62,5 %, en comparación al físico que tiene una prevalencia de 36,4% donde el principal problema es que no se comprendió la letra en un 86,7%. Conclusiones: El examen clínico odontológico es de extrema utilidad para colaborar en el proceso de identificación de víctimas mortales, sin embargo, se logró identificar, que no todos los profesionales en odontología en Costa Rica realizan una adecuada documentación en sus expedientes clínicos. Se propone una simbología estandararizada para dicha documentación.


Abstract Introduction: The objective of the research was to establish what is the symbology used by dentistry professionals to document the most common dental findings in their records; with the purpose of including it in a single standardized dental format for identification purposes in Costa Rica. Materials and methods: Through a questionnaire the symbology used by general dentists and specialists was identified and compared to record the dental findings in their files. A pilot phase with 8 questionnaires was carried out and after the corrections, it was applied to a sample of 49 dentists that included general and all specialties dentists. The statistical techniques used for the analysis of the information collected in the surveys are frequency distributions, crossing of variables, comparison of means based on the analysis of variance. The minimum level of confidence for the comparisons was 95%. The statistical processing of the data was designed a database created in EPI-INFO 6.4, the statistical processing of the data was performed in SPSS version 13.0 and in Excel. Results: The sample was conformed by 49 participants, 56% were men and 44% women. The age varies between 25 and 65 years; the average age was 44.5 years (95% CI: 41.7 - 47.3) and a median age [1] of 43 years, which had no statistically significant difference (p = 0.552) between the average age between men and women. A 70% of dentists use physical records, while only 17% use digital records, and 13% use both; digital files present the majority of problems with 62.5%, compared to the written format who has a prevalence of 36.4% where the main problem is that the letter was not understood in an 86.7 %. Conclusions: Dental records are extremely useful to collaborate in the process of human identification in fatalities; however, it was possible to identify that not all dental professionals in Costa Rica make adequate documentation in their clinical records. A standardized symbology is proposed for such documentation.


Assuntos
Assistência Odontológica/organização & administração , Odontologia , Controle de Formulários e Registros , Administração da Prática Odontológica/organização & administração
19.
AJR Am J Roentgenol ; 214(4): 835-842, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32023118

RESUMO

OBJECTIVE. The objective of this study was to assess impact of a report template quality improvement (QI) initiative on use of preferred phrases for communicating normal findings in structured abdominal CT and MRI reports. SUBJECTS AND METHODS. This prospective QI initiative, designed to decrease use of equivocal phrases and increase use of preferred and acceptable phrases (defined by multidisciplinary experts including patient advocates) in radiology reports, was performed in an academic medical center with over 800,000 annual radiologic examinations and was exempt from institutional review board approval. The intervention populated the preferred term "normal" (default) and acceptable specified pertinent negative phrases (pick-list option) when describing abdominal organ subheadings (liver, pancreas, spleen, adrenal glands, kidneys) within the "Findings" heading of abdominal CT and MRI report templates. We tabulated frequencies of the term "normal", specified pertinent negatives, and equivocal phrases in 21,629 reports before (June 1, 2017, to February 28, 2018) and 23,051 reports after (April 1, 2018, to December 31, 2018) the intervention using natural language processing and recorded trainee participation in report generation. We assessed intervention impact using statistical process control (SPC) charts and the Fisher exact test. RESULTS. Equivocal phrases were used less frequently in abdominal CT and MRI reports for both attending radiologists and trainees after the intervention (p < 0.05, SPC). Use of the term "normal" increased for reports generated by attending radiologists alone but decreased for reports created with trainee participation (p < 0.05, SPC). Frequency of pertinent negatives increased for reports with trainee participation (p < 0.05, SPC). CONCLUSION. A QI intervention decreased use of equivocal terms and increased use of preferred and acceptable phrases when communicating normal findings in abdominal CT and MRI reports.


Assuntos
Controle de Formulários e Registros/normas , Imagem por Ressonância Magnética , Melhoria de Qualidade , Terminologia como Assunto , Tomografia Computadorizada por Raios X , Humanos , Estudos Prospectivos , Sistemas de Informação em Radiologia
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