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1.
South Med J ; 114(3): 150-155, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33655308

RESUMO

OBJECTIVES: Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans' reproductive needs, and the effect of training on documentation in a women's primary care clinic in Salt Lake City, Utah. METHODS: We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits. RESULTS: Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling. CONCLUSIONS: Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals.


Assuntos
Documentação/métodos , Serviços de Planejamento Familiar/educação , Capacitação em Serviço/métodos , Programas de Rastreamento/métodos , Inquéritos e Questionários/normas , Veteranos/psicologia , Adulto , Documentação/normas , Características da Família , Serviços de Planejamento Familiar/métodos , Serviços de Planejamento Familiar/normas , Feminino , Implementação de Plano de Saúde , Humanos , Programas de Rastreamento/normas , Projetos Piloto , Gravidez , Atenção Primária à Saúde , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos , Adulto Jovem
2.
J Nurs Adm ; 51(3): 162-167, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33570374

RESUMO

A focused effort is needed to capture the utility and usability of the electronic health record for providing usable and reusable data while reducing documentation burden. A collaborative effort of nurse leaders and experts was able to generate national consensus recommendations on documentation elements related to admission history. The process used in this effort is summarized in a framework that can be used by other groups to develop content that reduces documentation burden while maximizing the creation of usable and reusable data.


Assuntos
Gerenciamento de Dados/normas , Documentação/normas , Registros Eletrônicos de Saúde/normas , Colaboração Intersetorial , Objetivos Organizacionais , Guias de Prática Clínica como Assunto/normas , Humanos , Estados Unidos
3.
J Forensic Leg Med ; 78: 102107, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33422886

RESUMO

Torture and ill-treatment are crimes practiced systematically in many countries around the world. Little is known about the attitudes and experiences of health professionals who evaluate the victims of these crimes. This study was conducted to assess the attitudes and experiences of health professionals who conduct clinical evaluations of alleged torture and ill-treatment and identify common needs and challenges. Two surveys were administered to health professionals who attended a series of Istanbul Protocol (IP) trainings in various countries of Central Asia, Middle East/North Africa and Latin-America. The findings indicate that participants documented a significant number of torture and ill-treatment cases during a three-year period preceding the survey and that they were interested in conducting evaluations in accordance with the IP, but expressed concern about the impact of such evaluations on their workload and the effects of secondary trauma. Participants indicated support for a wide range of professional development and self-regulatory measures. The study also indicates the need for additional training and other measures to ensure effective documentation practices as 13% of participants failed to understand one of the most basic IP concepts - that the absence of physical and/or psychological evidence does not rule out the possibility that torture and/or ill-treatment occurred.


Assuntos
Atitude do Pessoal de Saúde , Vítimas de Crime , Guias como Assunto , Tortura , Adulto , Documentação/normas , Feminino , Pessoal de Saúde/educação , Pessoal de Saúde/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Exame Físico/normas , Testes Psicológicos/normas , Inquéritos e Questionários
4.
J Nurs Adm ; 51(1): 43-48, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33278201

RESUMO

OBJECTIVE: To examine changes in registered nurse (RN) perceptions of electronic documentation over a 4-year period. BACKGROUND: The investigators previously reported differences in RN perceptions prior to and 1 year after adoption of a comprehensive electronic health record (EHR). METHODS: Investigators repeated the study 4 years after adoption, using the Nurses' Perceptions of Electronic Documentation tool and interviews with a subset of RNs. RESULTS: Nurses scored higher on ease of use domain and lower on concern about the EHR domain and showed no difference on the impacts of the EHR domain. Interviews revealed that 4 years later, some aspects of documentation were easier; the tool was comprehensive, but not without risk, and nurses remained ambivalent about the EHR. CONCLUSIONS: Use of EHR technology impacts nursing work. It is important to understand how nurses' perceptions change over time. This study gives nursing leaders insight into adoption and acceptance of an EHR.


Assuntos
Documentação/normas , Enfermeiras e Enfermeiros/psicologia , Percepção , Atitude Frente aos Computadores , Documentação/métodos , Documentação/tendências , Registros Eletrônicos de Saúde/instrumentação , Registros Eletrônicos de Saúde/normas , Registros Eletrônicos de Saúde/tendências , Humanos , Enfermeiras e Enfermeiros/normas , Enfermeiras e Enfermeiros/tendências , Inquéritos e Questionários
5.
Medicine (Baltimore) ; 99(51): e23776, 2020 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-33371146

RESUMO

ABSTRACT: Whereas handover of pertinent information between hospital and primary care is necessary to ensure continuity of care and patient safety, both quality of content and timeliness of discharge summary need to be improved. This study aims to assess the impact of a quality improvement program on the quality and timeliness of the discharge summary/letter (DS/DL) in a University hospital with approximatively 40 clinical units using an Electronic medical record (EMR).A discharge documents (DD) quality improvement program including revision of the EMR, educational program, audit (using scoring of DD) and feedback with a ranking of clinical units, was conducted in our hospital between October 2016 and November 2018. Main outcome measures were the proportion of the DD given to the patient at discharge and the mean of the national score assessing the quality of the discharge documents (QDD score) with 95% confidence interval.Intermediate evaluation (2017) showed a significant improvement as the proportion of DD given to patients increased from 63% to 85% (P < .001) and mean QDD score rose from 41 (95%CI [36-46]) to 74/100 (95%CI [71-77]). In the final evaluation (2018), the proportion of DD given to the patient has reached 95% and the mean QDD score was 82/100 (95% CI [80-85]). The areas of the data for admission and discharge treatments remained the lowest level of compliance (44%).The involvement of doctors in the program and the challenge of participating units have fostered the improvement in the quality of the DD. However, the level of appropriation varied widely among clinical units and completeness of important information, such as discharge medications, remains in need of improvement.


Assuntos
Documentação/normas , Alta do Paciente/normas , Avaliação de Programas e Projetos de Saúde/métodos , Fatores de Tempo , Estudos Controlados Antes e Depois , Documentação/métodos , Documentação/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Paris , Alta do Paciente/estatística & dados numéricos , Melhoria de Qualidade
6.
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
7.
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
9.
J Clin Nurs ; 29(17-18): 3435-3444, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32562579

RESUMO

AIMS AND OBJECTIVES: To identify and describe nursing interventions in patient documentation in adult psychiatric outpatient setting and to explore the potential for using the Nursing Interventions Classification in documentation in this setting. BACKGROUND: Documentation is an important part of nurses' work, and in the psychiatric outpatient care setting, it can be time-consuming. Only very few research reports are available on nursing documentation in this care setting. METHODS: A qualitative analysis of secondary data consisting of nursing documentation for 79 patients in four outpatient units (years 2016-2017). The data consisted of 1,150 free-text entries describing a contact or an attempted contact with 79 patients, their family members or supporting networks and 17 nursing care summaries. Deductive and inductive content analysis was used. SRQR guideline was used for reporting. RESULTS: We identified 71 different nursing interventions, 64 of which are described in the Nursing Interventions Classification. Surveillance and Care Coordination were the most common interventions. The analysis revealed two perspectives which challenge the use of the classification: the problem of overlapping interventions and the difficulty of naming group-based interventions. CONCLUSION: There is an urgent need to improve patient documentation in the adult psychiatric outpatient care setting, and standardised nursing terminologies such as the Nursing Interventions Classification could be a solution to this. However, the problems of overlapping interventions and naming group-based interventions suggest that the classification needs to be further developed before it can fully support the systematic documentation of nursing interventions in the psychiatric outpatient care setting. RELEVANCE TO CLINICAL PRACTICE: This study describes possibilities of using a systematic nursing language to describe the interventions nurses use in the adult psychiatric outpatient setting. It also describes problems in the current free text-based documentation.


Assuntos
Documentação/normas , Registros de Enfermagem/normas , Terminologia Padronizada em Enfermagem , Adulto , Assistência Ambulatorial/normas , Humanos , Enfermagem Psiquiátrica/métodos , Pesquisa Qualitativa
10.
Value Health ; 23(6): 689-696, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32540225

RESUMO

OBJECTIVES: Value and health technology assessment (V/HTA) is often used in clinical, access, and reimbursement decisions. V/HTA data-source selection may not be transparent, which is a necessary element for stakeholder understanding and trust and for fostering accountability among decision makers. Peer review is considered one mechanism for judging data trustworthiness. Our objective was (1) to use publicly available documentation of V/HTA methods to identify requirements for inclusion of peer-reviewed evidence sources, (2) to compare and contrast US and non-US approaches, and (3) to assess evidence sources used in published V/HTA reports. METHODS: Publicly available methods documentation from 11 V/HTA organizations in North America and Europe were manually searched and abstracted for descriptions of requirements and recommendations regarding search strategy and evidence-source selection. The bibliographies of a subset of V/HTA reports published in 2018 were manually abstracted for evidence-source types used in each. RESULTS: Heterogeneity in evidence-source retrieval and selection was observed across all V/HTA organizations, with more pronounced differences between US and non-US organizations. Not all documentation of organizations' methods address the evidence-source selection processes (7 of 11), and few explicitly reference peer-reviewed sources (3 of 11). Documentation of the evidence-source selection strategy was inconsistent across reports (6 of 13), and the level of detail provided varied across organizations. Some information on evidence-source selection was often included in confidential documentation and was not publicly available. CONCLUSIONS: Disparities exist among V/HTA organizations in requirements and guidance regarding evidence-source selection. Standardization of evidence-source selection strategies and documentation could help improve V/HTA transparency and has implications for decision making based on report findings.


Assuntos
Documentação/normas , Revisão por Pares , Avaliação da Tecnologia Biomédica/métodos , Europa (Continente) , Humanos , América do Norte
11.
Neurology ; 95(2): e213-e223, 2020 07 14.
Artigo em Inglês | MEDLINE | ID: mdl-32546650

RESUMO

OBJECTIVE: To incorporate standardized documentation into an epilepsy clinic and to use these standardized data to compare patients' perception of epilepsy diagnosis to provider documentation. METHODS: Using quality improvement methodology, we implemented interventions to increase documentation of epilepsy diagnosis, seizure frequency, and type from 49.8% to 70% of adult nonemployee patients seen by 6 providers over 5 months of routine clinical care. The main intervention consisted of an interactive SmartPhrase that mirrored a documentation template developed by the Epilepsy Learning Healthcare System. We assessed the weekly proportion of complete SmartPhrases among eligible patient encounters with a statistical process control chart. We used a subset of patients with established epilepsy care linked to existing patient-reported survey data to examine the proportion of patient-to-provider agreement on epilepsy diagnosis (yes vs no/unsure). We also examined sociodemographic and clinical characteristics of patients who disagreed vs agreed with provider's documentation of epilepsy diagnosis. RESULTS: The median SmartPhrase weekly completion rate was 78%. Established patients disagreed with providers with respect to epilepsy diagnosis in 18.5% of encounters (κ = 0.13), indicating that they did not have or were unsure if they had epilepsy despite having a provider-documented epilepsy diagnosis. Patients who disagreed with providers were similar to those who agreed with respect to age, sex, ethnicity, marital status, seizure frequency, type, and other quality-of-life measures. CONCLUSION: This project supports the feasibility of implementing standardized documentation of data relevant to epilepsy care in a tertiary epilepsy clinic and highlights an opportunity for improvement in patient-provider communication.


Assuntos
Documentação/normas , Epilepsia/terapia , Pessoal de Saúde/normas , Adulto , Comunicação , Epilepsia/psicologia , Feminino , Humanos , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Qualidade de Vida , Convulsões/classificação , Convulsões/epidemiologia , Fatores Socioeconômicos , Inquéritos e Questionários , Centros de Atenção Terciária/normas , Resultado do Tratamento
12.
JAMA Netw Open ; 3(6): e205867, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32515797

RESUMO

Importance: As health information transparency increases, patients more often seek their health data. More than 44 million patients in the US can now readily access their ambulatory visit notes online, and the practice is increasing abroad. Few studies have assessed documentation errors that patients identify in their notes and how these may inform patient engagement and safety strategies. Objective: To assess the frequency and types of errors identified by patients who read open ambulatory visit notes. Design, Setting, and Participants: In this survey study, a total of 136 815 patients at 3 US health care organizations with open notes, including 79 academic and community ambulatory care practices, received invitations to an online survey from June 5 to October 20, 2017. Patients who had at least 1 ambulatory note and had logged onto the portal at least once in the past 12 months were included. Data analysis was performed from July 3, 2018, to April 27, 2020. Exposures: Access to ambulatory care open notes through patient portals for up to 7 years (2010-2017). Main Outcomes and Measures: Proportion of patients reporting a mistake and how serious they perceived the mistake to be, factors associated with finding errors characterized by patients as serious, and categories of patient-reported errors. Results: Of 136 815 patients who received survey invitations, 29 656 (21.7%) responded and 22 889 patients (mean [SD] age, 55.16 [15.96] years; 14 447 [63.1%] female; 18 301 [80.0%] white) read 1 or more notes in the past 12 months and completed error questions. Of these patients, 4830 (21.1%) reported a perceived mistake and 2043 (42.3%) reported that the mistake was serious (somewhat serious: 1563 [32.4%]; very serious: 480 [9.9%]). In multivariable analysis, female patients (relative risk [RR], 1.79; 95% CI, 1.72-1.85), more educated patients (RR, 1.38; 95% CI, 1.29-1.48), sicker patients (RR, 1.89; 95% CI, 1.84-1.94), those aged 45 to 64 years (RR, 2.23; 95% CI, 2.06-2.42), those 65 years or older (RR, 2.00; 95% CI, 1.73-2.32), and those who read more than 1 note (2-3 notes: RR, 1.82; 95% CI, 1.34-2.47; ≥4 notes: RR, 3.09; 95% CI, 2.02-4.73) were more likely to report a mistake that they found to be serious compared with their reference groups. After categorization of patient-reported very serious mistakes, those specifically mentioning the word diagnosis or describing a specific error in current or past diagnoses were most common (98 of 356 [27.5%]), followed by inaccurate medical history (85 of 356 [23.9%]), medications or allergies (50 of 356 [14.0%]), and tests, procedures, or results (30 of 356 [8.4%]). A total of 23 (6.5%) reflected notes reportedly written on the wrong patient. Of 433 very serious errors, 255 (58.9%) included at least 1 perceived error potentially associated with the diagnostic process (eg, history, physical examination, tests, referrals, and communication). Conclusions and Relevance: In this study, patients who read ambulatory notes online perceived mistakes, a substantial proportion of which they found to be serious. Older and sicker patients were twice as likely to report a serious error compared with younger and healthier patients, indicating important safety and quality implications. Sharing notes with patients may help engage them to improve record accuracy and health care safety together with practitioners.


Assuntos
Confiabilidade dos Dados , Documentação/normas , Registros Eletrônicos de Saúde/estatística & dados numéricos , Registros Eletrônicos de Saúde/normas , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Idoso , Assistência Ambulatorial , Americanos Asiáticos/estatística & dados numéricos , Testes Diagnósticos de Rotina , Escolaridade , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Anamnese , Reconciliação de Medicamentos , Pessoa de Meia-Idade , Gravidade do Paciente , Fatores Sexuais , Inquéritos e Questionários , Adulto Jovem
13.
Orv Hetil ; 161(21): 873-880, 2020 05.
Artigo em Húngaro | MEDLINE | ID: mdl-32427572

RESUMO

Introduction, aim: Quality control of patient documentation for cerebral palsy (CP) at Semmelweis University. METHOD: In our retrospective audit, we revised patient records for all children born between 2005 and 2015, with suspected CP, registering 673 cases with confirmed CP. Based on the available patient data, we assessed clinical and etiological classification of CP and data availability. RESULTS: Patient records of 86% of children were suitable for clinical classification. Among them, 90.5% were spastic, 7.8% hypotonic, 1.2% dyskinetic and 0.5% ataxic. Among the classifiable spastic cases (98% of all spastic cases), 51% presented with tetraparetic/tetraplegic, 26% diparetic/diplegic and 23% hemiparetic/hemiplegic localization; in the remaining 2%, sufficient data for topological classification was unavailable. Severity assessed on Gross Motor Function Classification System was definable in 82% of cases, 43% showing grade I-II, 28% grade III and 29% grade IV-V impairment. Patient history was specified in 91% of cases. Prematurity was documented in 55%, perinatal asphyxia/hypoxic-ischemic encephalopathy in 31%, intraventricular/intracranial haemorrhage in 27%, multiple births in 19%, intrauterine growth restriction in 18%, intrauterine/perinatal/infancy infection in 15%, congenital malformation in 12%, in vitro fertilisation in 5%, stroke in 3% and CP-associated genetic mutation in 3% of cases. Negative patient history was determined in 16% of children. CONCLUSIONS: Our audit established that clinical documentation of CP is performed based on uniform criteria, detecting missing data primarily in clinical classification and patient history. We propose a patient documentation standard in the clinical care of affected children, which is a prerequisite for unified data recording and a future national CP registry. Orv Hetil. 2020; 161(21): 873-880.


Assuntos
Paralisia Cerebral/epidemiologia , Auditoria Clínica , Confiabilidade dos Dados , Documentação/normas , Criança , Feminino , Humanos , Recém-Nascido , Gravidez , Prevalência , Estudos Retrospectivos , Universidades
15.
J Surg Res ; 253: 79-85, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32335394

RESUMO

BACKGROUND: The American College of Surgeons Commission on Cancer has incorporated documentation of critical elements outlined in Operative Standards for Cancer Surgery into revised standards for cancer center accreditation. This study assessed the current documentation of critical elements in partial mastectomy (PM) and sentinel lymph node biopsy (SLNB) operative reports. MATERIALS AND METHODS: Operative reports for PM + SLNB at a single academic institution from 2013 to 2018 were reviewed for compliance and surveyor interobserver reliability with the Oncologic Elements of Operative Record defined in Operative Standards and compared with a nonredundant American Society of Breast Surgeons Mastery of Breast Surgery (MBS) quality measure for specimen orientation. RESULTS: Ten reviewers each evaluated 66 PM + SLNB operative reports for 13 Oncologic Elements and one MBS measure. No operative records reported all critical elements for PM + SLNB or PM alone. Residents completed 36.4% of operative reports: Element documentation was similar for PM but varied significantly for SLNB between resident and attending authorship. Combined reporting performance and interrater reliability varied across all elements and was highest for the use of SLNB tracer (97.1% and κ = 0.95, respectively) and lowest for intraoperative assessment of SLNB (30.6%, κ = 0.43). MBS specimen orientation had both high proportion reported (87.0%) and interrater reliability (κ = 0.84). CONCLUSIONS: Adherence to reporting critical elements for PM and SLNB varied. Whether differential compliance was tied to discrepancies in documentation or reviewer abstraction, clarification of synoptic choices may improve reporting consistency. Evolving techniques or technologies will require continuous appraisal of mandated reporting for breast surgery.


Assuntos
Acreditação/normas , Neoplasias da Mama/cirurgia , Documentação/normas , Excisão de Linfonodo/estatística & dados numéricos , Mastectomia Segmentar/estatística & dados numéricos , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/normas , Centros Médicos Acadêmicos/estatística & dados numéricos , Mama/patologia , Mama/cirurgia , Neoplasias da Mama/patologia , Institutos de Câncer/organização & administração , Institutos de Câncer/normas , Institutos de Câncer/estatística & dados numéricos , Documentação/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Excisão de Linfonodo/instrumentação , Excisão de Linfonodo/métodos , Excisão de Linfonodo/normas , Mastectomia Segmentar/instrumentação , Mastectomia Segmentar/métodos , Mastectomia Segmentar/normas , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Reprodutibilidade dos Testes , Biópsia de Linfonodo Sentinela/normas , Biópsia de Linfonodo Sentinela/estatística & dados numéricos
17.
BMC Palliat Care ; 19(1): 32, 2020 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-32183800

RESUMO

BACKGROUND: To improve the quality of advance care planning (ACP) in primary care, it is important to understand the frequency of and topics involved in the ACP discussion between patients and their family physicians (FPs). METHODS: A secondary analysis of a previous multicenter cross-sectional observational study was performed. The primary outcome of this analysis was the frequency of and topics involved in the ACP discussion between outpatients and FPs. In March 2017, 22 family physicians at 17 clinics scheduled a day to assess outpatients and enrolled patients older than 65 years who were recognized by FPs as having regular visits. We defined three ACP discussion topics: 1) future decline in activities of daily living (ADL), 2) future inability to eat, and 3) surrogate decision makers. FPs assessed whether they had ever discussed any ACP topics with each patient and their family members, and if they had documented the results of these discussions in medical records before patients were enrolled in the present study. We defined patients as being at risk of deteriorating and dying if they had at least 2 positive general indicators or at least 1 positive disease-specific indicator in the Japanese version of the Supportive and Palliative Care Indicators Tool. RESULTS: In total, 382 patients with a mean age of 77.4 ± 7.9 years were enrolled, and 63.1% were female. Seventy-nine patients (20.7%) had discussed at least one ACP topic with their FPs. However, only 23 patients (6.0%) had discussed an ACP topic with family members and their FPs, with the results being documented in their medical records. The topic of future ADL decline was discussed and documented more often than the other two topics. Patients at risk of deteriorating and dying discussed ACP topics significantly more often than those not at risk of deteriorating and dying (39.4% vs. 16.8%, p < 0.001). CONCLUSION: FPs may discuss ACP with some of their patients, but may not often document the results of this discussion in medical records. FPs need to be encouraged to discuss ACP with patients and family members and describe the decisions reached in medical records.


Assuntos
Planejamento Antecipado de Cuidados/classificação , Documentação/normas , Atenção Primária à Saúde/normas , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Documentação/classificação , Documentação/estatística & dados numéricos , Feminino , Humanos , Japão , Masculino , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos
18.
Int J Evid Based Healthc ; 18(1): 75-85, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32141949

RESUMO

AIM: The aim of this evidence implementation project was to improve the documentation of chemotherapy administration by nursing staff in a bone marrow transplant unit, to improve patient care and safety, as well as meet the legal and educational responsibilities of the nursing staff. METHODS: This evidence implementation project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback framework for the design and development of an evidence-based audit and feedback change project. A baseline audit was conducted to assess current practices against best practice and identify areas requiring improvement. Next, the project team reflected on the results of the audit to develop and implement strategies for documentation improvement. Lastly, a follow-up audit was conducted to assess changes in practice improvement. RESULTS: The baseline audit results revealed practice areas requiring improvement; facilitators of and barriers to nursing documentation and practice improvement were identified. A checklist, educational session, Nursing Documentation Guidelines for Chemotherapy Administration, was implemented to improve nursing documentation. The follow-up audit demonstrated improved adherence across all audit criteria. CONCLUSION: The checklist implemented for nursing documentation and education contributed to improved practices. To promote additional improvements, nurses will continue to utilize the tools developed and receive continued education through formal training and staff meetings. Future auditing is planned to ensure sustainability.


Assuntos
Antineoplásicos/administração & dosagem , Transplante de Medula Óssea , Documentação/normas , Enfermagem Oncológica/métodos , Antineoplásicos/efeitos adversos , Brasil , Lista de Checagem/métodos , Fidelidade a Diretrizes , Hospitais Universitários , Humanos , Recursos Humanos de Enfermagem no Hospital/normas , Enfermagem Oncológica/educação , Guias de Prática Clínica como Assunto
19.
BMJ Open Qual ; 9(1)2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32213549

RESUMO

A point-of-care ultrasound scan (POCUS) is a core element of the Royal College of Emergency Medicine (RCEM) specialty training curriculum. However, POCUS documentation quality can be poor, especially in the time-pressured environment of the emergency department (ED). A survey of 10 junior ED clinicians at the Princess Royal University Hospital (PRUH) found that total POCUS documentation was as low as 38% in some examinations.This quality improvement project aimed to increase the coverage and quality of POCUS documentation in the ED. This was done by using a plan-do-study-act (PDSA) regime to improve the quality of POCUS documentation from the original baseline to 80%. There were three discreet PDSA cycles and the interventions included improving education and training about POCUS documentation and the introduction of an original proforma, which incorporated six minimum requirements for POCUS documentation as per the joint RCEM and Royal College of Radiologists (RCR) guidelines for POCUS documentation (patient details, indications, findings, conclusions, signature and date).The project team audited the quality of all documented scans in the resuscitation department of the PRUH against the RCEM/RCR guidelines at baseline and following three discrete PDSA cycles. This was done over an 8-week period, spanning 696 attendances to the resuscitation area of the ED and 42 documented POCUS examinations.Quality recording of the six RCEM/RCR elements of POCUS documentation was poor at baseline but improved following three successful PDSA cycles. There was a demonstrated improvement in five of six documentation elements: patient details on POCUS documentation increased from 53.3% to the 66.7%, indication from 60.0% to 66.7%, conclusion from 13.0% to 83.0%, signature from 86.7% to 100.0% and date from 46.7% to 66.7%.These results suggest that the introduction of a proforma and a vigorous education strategy are effective ways to improve the quality of documentation of ED POCUS.


Assuntos
Documentação/normas , Ultrassonografia/tendências , Documentação/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Humanos , Sistemas Automatizados de Assistência Junto ao Leito/estatística & dados numéricos , Sistemas Automatizados de Assistência Junto ao Leito/tendências , Melhoria de Qualidade , Inquéritos e Questionários , Ultrassonografia/métodos , Ultrassonografia/estatística & dados numéricos
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