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1.
Perm J ; 242020.
Artigo em Inglês | MEDLINE | ID: mdl-32956034

RESUMO

Coronavirus disease 2019 (COVID-19) is a new, rapidly spreading pandemic that can lead to a life-threatening disease. Accurate and transparent COVID-19 case reports provide systematic clinical observations supporting researchers designing clinical trials and clinicians delivering health care. The checklist described here is designed to systematically and accurately capture data from case reports and case series for documentation on COVID-19. It is aligned with the CARE guidelines, available from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network.


Assuntos
Lista de Checagem , Infecções por Coronavirus/terapia , Documentação , Pneumonia Viral/terapia , Infecções por Coronavirus/epidemiologia , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto
2.
Pediatr Emerg Care ; 36(9): 424-429, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32870615

RESUMO

OBJECTIVES: Suicide is a leading cause of adolescent death, and emergency department (ED) visits are recognized as an opportunity to identify at-risk youth. For patients screening positive for mental health concerns, we implemented a quality improvement initiative to enhance documentation of results and interventions in the ED, increase communication between the ED and primary care providers (PCPs), and increase PCP follow-up. METHODS: Interventions included education, feedback, and an alert in our electronic health record. Completion of a Behavioral Health Screen (BHS-ED) initiates an alert that reminds ED providers how to document and communicate results and needed follow-up to the PCP. We reviewed a random monthly sample of ED charts for adolescents 14 to 19 years old presenting with nonpsychiatric complaints who screened positive for severe depression or suicidality. Outcome measures included documentation of BHS-ED results in the ED note, communication of positive results to the PCP, PCP follow-up of results, and ED return visits. RESULTS: Documentation of BHS-ED results increased from 73% at baseline to 88% of patients after the intervention. For patients discharged from the ED with nonpsychiatric chief complaints, communication to PCPs increased from 1% at baseline to 40% during the final 3 months of the study. When PCP communication occurred, 67% of in-network PCPs followed up with patients versus 5% when no communication took place from the ED. CONCLUSIONS: A multifaceted intervention including education and an electronic health record alert improved ED documentation, communication, and PCP follow-up of issues identified during ED-based mental health screens.


Assuntos
Comunicação , Registros Eletrônicos de Saúde , Serviço Hospitalar de Emergência , Saúde Mental , Sumários de Alta do Paciente Hospitalar , Atenção Primária à Saúde , Adolescente , Assistência ao Convalescente , Depressão/diagnóstico , Documentação , Humanos , Capacitação em Serviço , Programas de Rastreamento , Melhoria de Qualidade , Suicídio/prevenção & controle , Adulto Jovem
3.
S Afr Med J ; 110(7): 607-609, 2020 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-32880331

RESUMO

Tuberculosis (TB) is a curable disease, but continues to contribute to large numbers of deaths globally and remains among the leading causes of death in South Africa (SA). Evaluating trends in TB deaths and progress towards the End TB strategy target of zero deaths is particularly important to guide policy and practice in SA. TB deaths are complicated by its relationship with HIV, and SA's initial slow response to HIV compounded this. In considering the reported deaths in SA that identify TB as the underlying cause of death, it is important to be aware of potential limitations and sources of bias. We have examined the relationship between TB and HIV and the recording of underlying and contributing causes of death, and clarified the World Health Organization's methodology for estimating TB deaths.


Assuntos
Tuberculose/mortalidade , Causas de Morte , Atestado de Óbito , Documentação , Infecções por HIV/mortalidade , Humanos , África do Sul/epidemiologia , Estatísticas Vitais , Organização Mundial da Saúde
4.
Stud Health Technol Inform ; 274: 174-188, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32990673

RESUMO

eHealth is the use of modern information and communication technology (ICT) for trans-institutional healthcare purposes. Important subtopics of eHealth are health data sharing and telemedicine. Most of the clinical documentation to be shared is collected in patient records to support patient care. More sophisticated approaches to electronic patient records are trans-institutional or (inter-)national. Other aims for clinical documentation are quality management, reimbursement, legal issues, and medical research. Basic prerequisite for eHealth is interoperability, which can be divided into technical, semantic and process interoperability. There is a variety of international standards to support interoperability. Telemedicine is a subtopic of eHealth, which bridges spatial distance by using ICT for medical (inter-)actions. We distinguish telemedicine among healthcare professionals and telemedicine between health care professionals and patients. Both have a great potential to face the challenges of aging societies, the increasing number of chronically ill patients, multimorbidity and low number of physicians in remote areas. With ongoing digitalization more and more data are available digitally. Clinical documentation is an important source for big data analysis and artificial intelligence. The patient has an important role: Telemonitoring, wearable technologies, and smart home devices provide digital health data from daily life. These are high-quality data which can be used for medical decisions.


Assuntos
Inteligência Artificial , Telemedicina , Assistência à Saúde , Documentação , Registros Eletrônicos de Saúde , Humanos
5.
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
6.
Healthc (Amst) ; 8(3): 100454, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32919584

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic challenged health care organizations to develop ways to provide patient care with rapidly changing guidelines and scarce resources. Clinical leaders and informatics specialists partnered to rapidly develop an electronic health record (EHR) template for primary care staff to screen Veterans at Veterans Affairs (VA) Puget Sound. The template prompts categorization of patients by stability and suspicion for COVID-19, and provides just-in-time triaging advice for clinic staff. Each category is a discrete data element and this information was used by leadership to track screening and testing volumes. We found that a brief, practical EHR note template can be quickly adopted to inform guideline-based screening, direct patient care, and conserve resources.


Assuntos
Infecções por Coronavirus/diagnóstico , Documentação , Registros Eletrônicos de Saúde , Programas de Rastreamento/normas , Pneumonia Viral/diagnóstico , Betacoronavirus , Humanos , Liderança , Pandemias , Estados Unidos , United States Department of Veterans Affairs
7.
PLoS Comput Biol ; 16(9): e1008095, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32881868

RESUMO

Research publications and data nowadays should be publicly available on the internet and, theoretically, usable for everyone to develop further research, products, or services. The long-term accessibility of research data is, therefore, fundamental in the economy of the research production process. However, the availability of data is not sufficient by itself, but also their quality must be verifiable. Measures to ensure reuse and reproducibility need to include the entire research life cycle, from the experimental design to the generation of data, quality control, statistical analysis, interpretation, and validation of the results. Hence, high-quality records, particularly for providing a string of documents for the verifiable origin of data, are essential elements that can act as a certificate for potential users (customers). These records also improve the traceability and transparency of data and processes, therefore, improving the reliability of results. Standards for data acquisition, analysis, and documentation have been fostered in the last decade driven by grassroot initiatives of researchers and organizations such as the Research Data Alliance (RDA). Nevertheless, what is still largely missing in the life science academic research are agreed procedures for complex routine research workflows. Here, well-crafted documentation like standard operating procedures (SOPs) offer clear direction and instructions specifically designed to avoid deviations as an absolute necessity for reproducibility. Therefore, this paper provides a standardized workflow that explains step by step how to write an SOP to be used as a starting point for appropriate research documentation.


Assuntos
Métodos , Registros , Redação/normas , Documentação , Humanos , Reprodutibilidade dos Testes , Projetos de Pesquisa/normas , Fluxo de Trabalho
8.
Radiol Clin North Am ; 58(5): 925-933, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32792124

RESUMO

Given the incidence of small renal masses, from benign cysts to malignancy, most radiologists encounter these lesions multiple times during their career. Radiologists have an opportunity to provide critical data that will further refine the understanding of the impact of these masses on patient outcomes. This article summarizes and describes recent updates and understanding of the critical observations and descriptors of renal masses. The templates and glossary of terms presented in this review article facilitate the radiology reporting of such data elements, giving radiologists the opportunity to improve diagnostic accuracy and influence management of small renal masses.


Assuntos
Documentação/métodos , Neoplasias Renais/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Terminologia como Assunto , Tomografia Computadorizada por Raios X/métodos , Humanos , Rim/diagnóstico por imagem
9.
Environ Monit Assess ; 192(8): 552, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32737629

RESUMO

The high-altitude regions of Himalaya are among the best indicators of climate change yet noticeable for the lack of climate monitoring stations. However, they support ethnic communities whose livelihood activities are climate driven. Consequently, these communities are keen observers of the same and documenting their perception on changing climate is now an important area of global research. Therefore, the present study was conducted with the prime objective of documenting the climate change perception of Bhangalis-a resident community of western Himalaya, and analyzing variation in their perceptions in relation to age and gender. For this, respondent surveys (household, n = 430; individual interviews, n = 240) were carried out and the collected data were subjected to statistical analyses. The study also validated the perception of Bhangalis using the available weather data (1974-2017) through the Mann-Kendall test. The results reveal that Bhangalis perceived 11 indicators of changing climate, of which decrease in snowfall was the most prominent (reported by ~ 97% of the respondents). The perceptions varied between the two genders with males having significantly higher proportion of responses for all the 11 indicators. Similarly, differences in perception among the age groups were also observed, elderly people reported higher proportion of climate change indicators as compared to respondents of lower age. Notably, patterns of temperature and rainfall perceptions by the Bhangalis agreed with the trends of meteorological data. This highlights the importance of the study in documenting knowledge of ethnic communities especially from areas that lack monitoring stations. It argues for involving them in climate change programs.


Assuntos
Mudança Climática , Meteorologia , Idoso , Documentação , Monitoramento Ambiental , Feminino , Humanos , Masculino , Temperatura
10.
J Nurs Adm ; 50(9): 462-467, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32826515

RESUMO

OBJECTIVE: The aim of this study was to quantify the impact of electronic health record (EHR) workstation single sign-on (SSO) for nurses. BACKGROUND: SSO was implemented in 19 hospitals for expedited EHR access. METHODS: Login durations before and after SSO implementation were compared, and the financial value of nursing time liberated from keyboard was estimated. Stratified analyses show time liberated and financial value by staffing level and system size. RESULTS: First-of-shift login was reduced by 5.3 seconds (15.3%) and reconnect duration was reduced by 20.4 seconds (69.9%). SSO liberated 27,962.4 hours of nursing time from keyboard login per year across 19 facilities, and 1,471.7 hours/year/facility, valued at $52,112/facility and $990,128 for 19 hospitals. Time value ranges from $201,835 per year for a 5-hospital system with 300 nurses per facility to $672,790 per year for a 10-facility system with 500 nurses per hospital. CONCLUSIONS: Nurses gained substantial time liberated from EHR keyboard by SSO for patient care, having significant financial value for the organization.


Assuntos
Documentação/tendências , Registros Eletrônicos de Saúde , Hospitais/estatística & dados numéricos , Invenções/economia , Registros Eletrônicos de Saúde/economia , Registros Eletrônicos de Saúde/organização & administração , Humanos , Assistência ao Paciente , Fatores de Tempo
12.
BMC Bioinformatics ; 21(1): 290, 2020 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-32640981

RESUMO

BACKGROUND: Well-characterized biomaterials of high quality have great potential for acceleration and quality improvement in translational biomedical research. To improve accessibility of local sample collections, efforts have been made to create central biomaterial banks and catalogues. Available technical solutions for creating professional local sample catalogues and connecting them to central systems are cost intensive and/or technically complex to implement. Therefore, the Translational Thematic Unit HIV of the German Center for Infection Research (DZIF) developed a Laboratory Information and Management System (LIMS) called HIV Engaged Research Technology (HEnRY) for implementation into the Translational Platform HIV (TP-HIV) at the DZIF and other research networks. RESULTS: HEnRY is developed at the University Hospital of Cologne. It is an advanced LIMS to manage processing and storage of samples and aliquots of different sample types. Features include: monitoring of stored samples and associated information data selection via query tools or Structured Query Language (SQL) preparation of summary documents, including scannable search lists centralized management of the practical laboratory part of multicentre studies (e.g. import of drawing schemes and sample processing steps), preparation of aliquot shipments, including associated documents to be added to shipments unique and secure identification of aliquots through use of customizable Quick Response (QR) code labels directly from HEnRY support of aliquot data transmission to central registries. In summary, HEnRY offers all features necessary for a LIMS software. In addition, the structure of HEnRY provides sufficient flexibility to allow the implementation in other research areas. CONCLUSION: HEnRY is a free biobanking tool published under the MIT license. While it was developed to support HIV research in Germany, the feature set and language options, allow much broader applications and make this a powerful free research tool.


Assuntos
Bancos de Espécimes Biológicos , Software , Materiais Biocompatíveis , Sistemas Computacionais , Gerenciamento de Dados , Documentação , Humanos , Laboratórios , Estudos Multicêntricos como Assunto
13.
S Afr Med J ; 110(2): 140-144, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657686

RESUMO

BACKGROUND: Anaesthesia-related mortality is an important, potentially avoidable cause of perioperative mortality. A procedure-related death notification (PRDN) instrument is completed by relevant medical practitioners after a procedure-related death and is used to audit practice and identify areas of care that require improvement. It is also used in medicolegal investigations when establishing cause of death, and in the case of litigation. The current South African (SA) PRDN instrument, designated the GW7/24 form, contains both surgical and anaesthetic sections and is considered to be outdated, inadequate and in need of revision. OBJECTIVES: To develop and validate a revised anaesthetic section of the SA PRDN instrument that can be used for procedure-related deaths in future and be used to update the GW7/24 form for epidemiological, forensic or academic use. METHODS: Lynn's two-stage model was utilised. After an extensive literature review, a provisional PRDN instrument was developed. This provisional instrument was debated and reviewed at a peer group discussion in which 6 local experts took part. These experts were anaesthetic and forensic pathology specialists who specifically have expert knowledge on procedure-related deaths. A revised PRDN instrument was developed, which was then rated by 8 national experts using a Likert scale. The content validity index (CVI) for each item and for the instrument as a whole was then established. Items with a CVI <0.88 were removed to formulate the final PRDN instrument. RESULTS: The provisional PRDN instrument consisted of 14 domains and 66 items. The revised PRDN instrument consisted of 13 domains and 65 items, of which 3 items with a CVI <0.88 were removed. The final PRDN instrument, after minor revisions based on suggestions from the 8 national experts, consisted of 18 domains and 79 items. Every item on the form was declared relevant and important by the national experts, with the final instrument scoring an overall CVI of 1. CONCLUSIONS: A comprehensive, updated and validated anaesthetic section of the SA PRDN instrument was developed. This could be used as a government and anaesthesiology society-endorsed template when updating the current GW7/24 form.


Assuntos
Anestesia/mortalidade , Causas de Morte , Morte , Documentação/métodos , Documentação/normas , Humanos , Reprodutibilidade dos Testes , África do Sul
14.
Stud Health Technol Inform ; 272: 151-154, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604623

RESUMO

Decision models (DM), especially Markov Models, play an essential role in the economic evaluation of new medical interventions. The process of DM generation requires expert knowledge of the medical domain and is a time-consuming task. Therefore, the authors propose a new model generation software PrositNG that is connectable to database systems of real-world routine care data. The structure of the model is derived from the entries in a database system by the help of Machine Learning algorithms. The software was implemented with the programming language Java. Two data sources were successfully utilized to demonstrate the value of PrositNG. However, a good understanding of the local documentation routine and software is paramount to use real-world data for model generation.


Assuntos
Aprendizado de Máquina , Software , Bases de Dados Factuais , Documentação
15.
Stud Health Technol Inform ; 272: 233-236, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604644

RESUMO

A large amount of patient data is produced and documented in patient care. Health care professionals expect that this routinely collected patient data can also be used for secondary purposes such as measuring the quality of care or to gain new knowledge. Routine data needs to be documented in a standardized form, based on clinical terminologies, to allow this secondary use of data. In Austria, hospitals are currently moving from paper-based documentation to computer-based documentation, but parts of the documentation are still done in paper-based form or without using clinical terminologies, especially in nursing. This study aims to analyze the availability of standardized electronic patient data in nursing in Austria. We conducted an online survey of 32 senior nursing managers at 32 Austrian hospitals. The study showed that 79% of hospitals use electronic health records for nursing documentation, but only 29% of the nursing care plans are documented in a standardized way using standardized nursing classification systems such as NANDA-I.


Assuntos
Terminologia Padronizada em Enfermagem , Áustria , Documentação , Registros Eletrônicos de Saúde , Humanos , Registros de Enfermagem , Inquéritos e Questionários
16.
Stud Health Technol Inform ; 272: 261-264, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604651

RESUMO

The dissemination of Clinical Decision Support Systems (CDSS) in the medical field is slow due to various reasons such as lacking comprehensibility, low user acceptance, specific problem settings and unique application environments. This paper presents an illustration of the complexity of the CDS development process. Guided by procedural software development models already known from the field of software engineering, we developed a CDS-specific software lifecycle and a CDS development complexity illustration. We based the results on literature research of publicated field reports about successfully developed CDSS. We identified important CDS peculiarities related to the development and documentation process of CDSS and later merged them with generic software engineering models. We then created a CDS complexity illustration that can be used to structure future research in the CDS field as well as any standardisation processes.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Documentação , Software
17.
S Afr Med J ; 110(5): 396-399, 2020 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657724

RESUMO

BACKGROUND: Some patients need referral within the health system to achieve optimal care, and referral letters are an important part of this process. Healthcare practitioners often complain that referral letters lack information, are inaccurate, or direct patients to the wrong place. Poor communication affects patient experience and outcomes, has budgetary and service planning implications, and impacts on staff relationships and morale. OBJECTIVES: To investigate the quality and appropriateness of referral letters received by the medical outpatient department of a regional hospital in Eastern Cape Province, South Africa. METHODS: Letters were collected by departmental staff as patients arrived at the clinic. Each letter was independently analysed by two healthcare workers for content and appropriateness, using defined criteria. RESULTS: Of 100 letters collected between March and May 2017, 85 were suitable for analysis. Patient and clinician identifiers were present in >85%, but key clinical information was missing in 87%, and 48% did not state a reason for referral. It was possible to make triage decisions based on the letter in only 35% of cases. Nineteen percent of referrals were classified as inappropriate. CONCLUSIONS: Most letters lacked important clinical information, probably because of a combination of factors: gaps in clinical knowledge of referring clinicians who service a population with a high burden of disease and complex pathology; under-resourced peripheral healthcare clinics; inadequate staff-to-patient ratios; and time constraints. A suggested focus for improvement is education at undergraduate and postgraduate level, which should emphasise preparation for community service, specifically highlighting techniques for preparing good-quality referrals.


Assuntos
Documentação/normas , Encaminhamento e Consulta , Humanos , Auditoria Médica , Ambulatório Hospitalar , Estudos Prospectivos , África do Sul
19.
Waste Manag Res ; 38(9): 923-941, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32635832

RESUMO

Waste from the construction sector poses huge challenges for sustainable waste management. This is not only due to the vast amount of waste produced in construction and demolition activities, but also due to pollutants potentially contained in these products. Subject to these conditions, waste management must ensure recovery of as many resources as possible, while making sure to keep material loops clean. This demanding task requires more knowledge about the existing building stock and an adaptation of current demolition processes. Innovative technologies, such as Building Information Modelling, or modern frameworks, such as Geographic Information Systems, offer a high potential to synoptically provide stock material information for future demolition activities for individual objects to be deconstructed as well as for whole cities as a basis for managing the anthropogenic stock and potential urban mining. Suitable methods of data collection allow for acquiring the desired input for the generation of building stock models enriched with demolition-related information. With the latter, selective deconstruction strategies as well as appropriate waste stream routing agendas can be planned and executed, thereby securing safety at work during the demolition process itself and a waste stream routing according to the waste hierarchy. This review article gives an overview of currently deployed building material assessment tools (data capture and visualisation), both a prerequisite for improved information on materials and geometry (and thereby mass/volume). In addition, this article describes workflows employable for the purpose of urban mining in end-of-life buildings, of which one holistic approach will be described in depth.


Assuntos
Indústria da Construção , Gerenciamento de Resíduos , Cidades , Materiais de Construção , Documentação , Sistemas de Informação Geográfica , Resíduos Industriais , Reciclagem
20.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32719089

RESUMO

Female genital mutilation or cutting (FGM/C) involves medically unnecessary cutting of parts or all of the external female genitalia. It is outlawed in the United States and much of the world but is still known to occur in more than 30 countries. FGM/C most often is performed on children, from infancy to adolescence, and has significant morbidity and mortality. In 2018, an estimated 200 million girls and women alive at that time had undergone FGM/C worldwide. Some estimate that more than 500 000 girls and women in the United States have had or are at risk for having FGM/C. However, pediatric prevalence of FGM/C is only estimated given that most pediatric cases remain undiagnosed both in countries of origin and in the Western world, including in the United States. It is a cultural practice not directly tied to any specific religion, ethnicity, or race and has occurred in the United States. Although it is mostly a pediatric practice, currently there is no standard FGM/C teaching required for health care providers who care for children, including pediatricians, family physicians, child abuse pediatricians, pediatric urologists, and pediatric urogynecologists. This clinical report is the first comprehensive summary of FGM/C in children and includes education regarding a standard-of-care approach for examination of external female genitalia at all health supervision examinations, diagnosis, complications, management, treatment, culturally sensitive discussion and counseling approaches, and legal and ethical considerations.


Assuntos
Circuncisão Feminina , Criança , Maus-Tratos Infantis , Cicatriz/etiologia , Circuncisão Feminina/efeitos adversos , Circuncisão Feminina/classificação , Circuncisão Feminina/legislação & jurisprudência , Circuncisão Feminina/psicologia , Competência Clínica , Confidencialidade , Documentação , Feminino , Doenças Urogenitais Femininas/etiologia , Procedimentos Cirúrgicos em Ginecologia , Humanos , Infecções/etiologia , Infertilidade Feminina/etiologia , Consentimento Livre e Esclarecido , Classificação Internacional de Doenças , Notificação de Abuso , Anamnese , Saúde Mental , Dor/etiologia , Pediatras , Exame Físico , Prevalência , Refugiados/legislação & jurisprudência , Sexualidade
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