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1.
Braz. j. oral sci ; 20: e219638, jan.-dez. 2021. tab
Artigo em Inglês | LILACS, BBO - Odontologia | ID: biblio-1254752

RESUMO

Diagnosis of oral and oropharyngeal cancer in advanced stages may be associated with social nature factors, access to health care, education, occupation, and behavioral/ cultural factors. Aim: To determine the factors related to high clinical-staging in patients diagnosed with squamous cell carcinoma in the oral and oropharyngeal region in a Cancer Center in Brazil between 2009 and 2015. Methods: It is an epidemiological, retrospective, and exploratory study. Patients diagnosed with squamous cell carcinoma had their medical records analyzed. The variables considered were sociodemographic, lifestyle, and disease characteristics. Descriptive and exploratory tests (Pearson's, chi-square test and, Student's t-test) were realized. Results: We analyzed 365 patient records, among which 289 (79.17%) were male, and 73 (20.0%) were female. Age ranged from 16 to 101 years, with a mean of 61.13. Regarding education, 157 (43.01%) studied < 8 years, 103 (28.21%) were illiterate and 102 (27.94%) studied > 8 years. 305 (83.56%) patients live in urban areas. There was an association between high clinical-staging and low educational level. For high clinical-staging, symptomatology, tobacco, and alcohol intake as well. Conclusion: Patients with low educational levels tend to report the disease later, and their diagnostics occurred in advanced stages. Thus, specific public health policies for this population, including access to dental care to recognize the clinical signs and early diagnosis, are necessary


Assuntos
Fatores Socioeconômicos , Neoplasias Bucais/diagnóstico , Neoplasias Orofaríngeas/diagnóstico , Registros Médicos
2.
Rev. cuba. inform. méd ; 13(1): e417, ene.-jun. 2021. graf
Artigo em Espanhol | LILACS, CUMED | ID: biblio-1251734

RESUMO

RESUMEN Los sistemas de información en los servicios de salud han contribuido en los procesos de automatización de historiales clínicos, desempeñando un papel importante en la atención médica. El objetivo de esta revisión ha sido identificar la importancia de los sistemas de información para la automatización de historiales clínicos y las herramientas usadas para su implementación. Se revisaron artículos de revistas indexadas en base de datos bibligráficas como: IEEE Digital Library, ScienceDirect, Scielo, Google Scholar con la finalidad de tener una mejor clasificación de información que aportara al desarrollo del contenido estudiado. Se identificó que los sistemas de información mejoran la comunicación médico-paciente, aceleran procesos de atención médica, reducen costos y tiempo. Los sistemas de información son importantes para la automatización de historiales clínicas, garantizado mejoras en el proceso de atención al paciente en los establecimientos de salud.


ABSTRACT Information systems in health services have contributed to the automation of medical records, playing an important role in medical care. The objective of this review was to identify the importance of information systems for the automation of medical records and the tools used for their implementation. Articles from journals indexed in bibliographic databases such as: IEEE Digital Library, ScienceDirect, Scielo, Google Scholar have been reviewed in order to have a better classification of information that contributes to the improvement of our interest topic. It has been identified that these information systems increase doctor-patient communication, speed up medical care processes, reduce costs and time. Information systems are important for the automation of medical records, guaranteeing advances in the patient care process in health establishments.


Assuntos
Humanos , Registros Médicos , Sistemas de Informação em Saúde , Sistemas de Informação em Saúde/normas
3.
Medicine (Baltimore) ; 100(23): e26300, 2021 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-34115036

RESUMO

ABSTRACT: In view of the renewed interest in psychedelics in psychiatry it is timely to analyze psychedelic treatment in historical cohorts. Recently the therapeutic efficacy of psychedelics has been linked to the so-called phenomenon of "connectedness." The aim of the present study was to explore whether long-lasting personality changes were observed in any of the 151 Danish psychiatric patients who were treated with Lysergic acid diethylamide (LSD) from 1960 to 1974.The exploration included a reanalysis of a subgroup as well from a 1964 Danish historical cohort. Medical records and other case materials of the above mentioned 151 patients are kept in the Danish State Archives. The present author was granted access to the LSD case materials in the Danish State Archives, and respected confidentiality per the Archives Law. According to the LSD Damages Law from 1986, they all received financial compensation for LSD-inflicted harm.Analysis did not reveal any personality changes such as "connectedness;" however, other lasting personality changes were observed in 2 to 4 patients and in quite a few patients unwanted effects persisted for weeks or months following acute treatment. In the present analysis of the 1964 cohort, the same percentage of patients improved with LSD treatment as in the historical analysis. In the latter, however, little attention was given to side effects, such as suicide attempts, suicides, and one homicide.Future psychedelic research with psychiatric patients should respect the potential toxicity of LSD and other psychedelics and meticulously monitor possible side effects.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Efeitos Adversos de Longa Duração , Dietilamida do Ácido Lisérgico , Transtornos Mentais , Personalidade/efeitos dos fármacos , Estudos de Coortes , Dinamarca , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/psicologia , Alucinógenos/administração & dosagem , Alucinógenos/efeitos adversos , Humanos , Efeitos Adversos de Longa Duração/induzido quimicamente , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/epidemiologia , Efeitos Adversos de Longa Duração/psicologia , Dietilamida do Ácido Lisérgico/administração & dosagem , Dietilamida do Ácido Lisérgico/efeitos adversos , Registros Médicos/estatística & dados numéricos , Transtornos Mentais/diagnóstico , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/epidemiologia , Medidas de Resultados Relatados pelo Paciente , Resultado do Tratamento
4.
Ther Adv Cardiovasc Dis ; 15: 17539447211012803, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34120532

RESUMO

BACKGROUND: Rates of obesity continue to rise worldwide as evidenced in the 2017 Centers for Disease Control and Prevention (CDC) report that indicated over 35% of United States (US) citizens are obese, with Louisiana ranked as the fifth most obese state in America. Since large clinical trials tend to exclude obese patients, health care providers are faced with concerns of under- or overdosing these patients on warfarin. METHODS: This retrospective chart review evaluated patients who reported to a community anticoagulation clinic for warfarin management between 1 June 2017 and 30 September 2017. Along with baseline demographics, chronic use of drugs that have clinically significant interactions with warfarin, social activity such as tobacco use and alcohol consumption, were collected. Body mass indexes (BMI) were collected and categorized according to the World Health Organization definitions as follows: Normal (BMI 18-24.9 kg/m2), Overweight (25-29.9 kg/m2), Obesity Class I (30-34.9 kg/m2), Obesity Class II (35-39.9 kg/m2), Obesity Class III (⩾40 kg/m2). The primary outcome was the mean 90-day warfarin dose required to maintain "intermediate control" or "good control" of international normalized ratio (INR), stratified by BMI classifications. The secondary outcome was the time in therapeutic range (TTR) stratified by BMI classifications. RESULTS: A total of 433 patient encounters were included in this study. There was a total of 43 encounters in the Normal BMI category, 111 Overweight encounters, 135 Obesity Class I encounters, 45 Obesity Class II encounters, and 99 Obesity Class III encounters. Approximately 63% of the study population were male, and over 90% the patients were African American. The Obesity Class I and Obesity Class II class required an average of 11.47 mg and 17.10 mg more warfarin, respectively, to maintain a therapeutic INR when compared with the Normal BMI category. These findings were statistically significant with p values of 0.007 and <0.001, respectively. Additionally, upon comparing the Overweight BMI category with the Obesity Class II category, there was a mean warfarin dose difference of 11.22 mg (p = 0.010) more in Obesity Class II encounters to maintain a therapeutic INR. In the secondary analysis of TTR, Overweight category encounters had the highest TTR, whereas encounters in the Normal BMI category had the lowest TTR. CONCLUSION: As BMI increases, there is an increased chronic warfarin requirement to maintain "intermediate control" or "good control" of INR between 2 and 3 in an ambulatory care setting.


Assuntos
Anticoagulantes/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Índice de Massa Corporal , Obesidade/diagnóstico , Varfarina/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/sangue , Cálculos da Dosagem de Medicamento , Interações Medicamentosas , Monitoramento de Medicamentos , Feminino , Humanos , Coeficiente Internacional Normatizado , Masculino , Registros Médicos , Pessoa de Meia-Idade , Obesidade/sangue , Obesidade/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo , Varfarina/sangue
5.
J Infect Public Health ; 14(7): 960-966, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34130120

RESUMO

BACKGROUND: Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, especially for the elderly and people who suffer from chronic conditions. This study was conducted to assess the clinical and microbiological characteristics and disease outcomes associated with the occurrence of CAP. METHODS: This retrospective chart review was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Cases with documented clinical diagnosis of CAP during the period from 2016 to 2019 were included. Data were collected on demographic, clinical, and microbiological characteristics, used antimicrobials and patients' outcomes, including length of hospital stay, intensive care unit admission, and mortality. Multivariate regression analysis was performed to identify risk factors for increased length of hospital stay. RESULTS: A total of two hundred and eighteen CAP episodes were identified. Patients had a median age of 64.5 years, and 54.1% were males. Microbiological diagnosis was established in 33 patients (15.1%). Admission to ICU and diagnosis of a neurological disease were significantly associated with longer hospital stay (>7 days). An average of 2.7 antimicrobials were used per patient, and the most common antibiotics used were Piperacillin/Tazobactam (46.3%), Doxycycline (44%), then Ceftriaxone (42.7%). Four patients (1.8%) died during hospital stay. CONCLUSIONS: This retrospective analysis of CAP cases identified a lack of microbiological diagnosis and increased burden associated with disease severity and the need for hospitalization. The ability to identify CAP at an earlier stage will be a cornerstone to mitigate its impact on the healthcare system and ICU units.


Assuntos
Infecções Comunitárias Adquiridas , Pneumonia , Idoso , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Hospitalização , Humanos , Tempo de Internação , Masculino , Registros Médicos , Pessoa de Meia-Idade , Pneumonia/diagnóstico , Pneumonia/tratamento farmacológico , Pneumonia/epidemiologia , Estudos Retrospectivos , Arábia Saudita/epidemiologia
6.
Pan Afr Med J ; 39: 1, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34178229

RESUMO

Introduction: Non-Communicable Diseases (NCD) are becoming a public health problem in Mozambique and wider sub-Saharan Africa, and are driving changes to guaranty lifelong follow up of patients within the health systems. Patient-Held Medical Records (PHMR) are an option for this follow-up in under-resourced health systems. We designed a study to assess the rate of retention and quality of conservation of the PHMR. Methods: we conducted a prospective observational study from November 2016 to October 2018 in a peri-urban hospital from in Mozambique. Consecutive newly diagnosed patients with cardiovascular disease were given PHMR. Data was collected after their first consultation and one year after. The retention and quality of conservation were assessed after 12 months. Results: overall 134 PHMR were given to patients (24;17.9% children and 77;57.5% female), of which 121 (90.3%) retained at 12 months (90.9% in good conservation state). Most patients had on average four visits to health facilities during the study, all registered in the PHMR. Retention could not be confirmed in 13 patients who did not return the PHMR. Conclusion: PHMR retention rates were high in an urban low-income setting in Africa, with high quality of conservation, thus supporting its use to replace hospital paper-based medical files. Specific research is recommended on acceptability, quality of information registered and patient´s perception.


Assuntos
Doenças Cardiovasculares/epidemiologia , Registros Médicos/estatística & dados numéricos , Doenças não Transmissíveis/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Doença Crônica/epidemiologia , Feminino , Humanos , Lactente , Masculino , Registros Médicos/normas , Pessoa de Meia-Idade , Moçambique , Estudos Prospectivos , Fatores de Tempo , População Urbana , Adulto Jovem
7.
Pan Afr Med J ; 38: 153, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33995760

RESUMO

Introduction: the medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This Process allows the sharing of files with both the health staff and patients, while respecting the professional confidentiality between parties. However, in Morocco, as is the case in other countries that are unable to computerize all their hospitals, it is necessary to study first the medical file in paper before proceeding with its computerization. The purpose of our study is to describe the state of the hard copy medical record in our Host University and international hospital, Cheikh Zaid in Morocco. Methods: that is a cross-sectional study that lasted for three months in Cheikh Zaid hospital. The collection of data from this institution was based on the evaluation of 100 medical records of inpatients, seeing as they respond to our study criteria and requirements better than outpatients. Said evaluation was inspired by a clinical audit grid recommended by the High Authority for Health (HAS). Extraction of the results is done using the SPSS 13.0, Microsoft Excel, and Microsoft Visio software. In addition, we used the observation method to correct the errors found. Results: the results showed that 75% of the files are in good condition and well organized. However, administrative documents were missing in 70% of the cases (national identity card, health insurance card and copy of the patient's consent form). Moreover, in 83% of cases, the identity of the person to be notified in case of complications and the consent form were missing. It is also the case for the discharge report. The latter is incomplete in 97% of the cases. Also, the file transfer data from one service to another were missing in 82% of the medical files. Conclusion: according to the results, improving the medical file is necessary both administratively and medically. Thus, all parties, including doctors and nurses must be aware of their tasks and roles in this process. Despite the advances in the computerization of the medical file in several hospitals in Morocco, the maintenance of the hard copy version remains unavoidable and still necessary, to protect the rights of both the patient and his medical staff.


Assuntos
Administração Hospitalar , Hospitais/normas , Registros Médicos/normas , Estudos Transversais , Humanos , Sistemas Computadorizados de Registros Médicos , Marrocos , Política
8.
BMC Med Inform Decis Mak ; 21(1): 155, 2021 05 13.
Artigo em Inglês | MEDLINE | ID: mdl-33985494

RESUMO

BACKGROUND: Injuries are a major health issue worldwide and their prevention requires access to accurate statistics in this regard. This can be achieved by classifying the collected data using the international classification systems. This study aimed at investigating the content coverage rate of the International Classification of External Causes of Injury (ICECI) regarding the external causes of injury in a hospital. METHODS: This cross-sectional descriptive-analytical study was performed on 322 injured individuals visiting the emergency unit of a hospital which is the biggest truma center in the southeast of Iran. The required data were collected via a designed questionnaire by the researcher visiting the Emergency ward. The collected data were encoded based on the ICECI textbook by two encoders. Their agreement rate was calculated using the Kappa estimate of agreement. The content coverage of the classification system and the degree of completeness of the required data for encoding in the patients' records were measured. Data were analyzed by the SPSS software, ver 19. RESULTS: The findings showed that 70% of the external causes of injury were covered by ICECI. Among the 322 cases, 138 (43%) had been referred due to a car crash. The injured were mostly drivers of land transport vehicles who had been unintentionally involved in a car crash. The least mechanism for injury was bite injury with 5 (2%). ICECI was capable of classifying 92% of the data related to the external causes of the injuries. The most un-covered data has belonged to the "activity when injured" axis (n = 18). Lack of precise data recording in the medical records resulted in missing data about at least one of the axis of the external causes in most records. CONCLUSION: The findings of the present study showed that ICECI has good content coverage for encoding the external causes of injuries. Before implementing ICECI for encoding the external causes of injuries, it is required to train clinicians regarding how to document all aspects of an injury incidence.


Assuntos
Serviço Hospitalar de Emergência , Ferimentos e Lesões , Causalidade , Estudos Transversais , Humanos , Irã (Geográfico) , Registros Médicos , Ferimentos e Lesões/epidemiologia
9.
Stud Health Technol Inform ; 281: 490-491, 2021 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-34042615

RESUMO

The problem list is a key facet of the digital patient record that has historically been difficult to curate. This paper presents an implementation of a contextual problem list using openEHR. It describes the modelling approach, key model elements, and how these are assembled to underpin a Problem Oriented Medical Record. Finally, it discusses issues associated with how problem lists may be used.


Assuntos
Registros Médicos Orientados a Problemas , Registros Médicos , Registros Eletrônicos de Saúde , Humanos
10.
Stud Health Technol Inform ; 281: 1085-1086, 2021 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-34042849

RESUMO

Web-based patient registries support clinicians by providing a way to effectively store and process data. Here, we present a new feature for the open-source registry software OSSE: medical reports generated with R Markdown. As part of a rare disease research project, we describe the process from requirements assessment to the current state of technical implementation. The feature offers clinicians the possibility to download customised as well as generic reports from an OSSE rare disease registry.


Assuntos
Doenças Raras , Software , Humanos , Registros Médicos , Doenças Raras/epidemiologia , Sistema de Registros
11.
Rev Med Suisse ; 17(740): 1052-1053, 2021 05 26.
Artigo em Francês | MEDLINE | ID: mdl-34042342
12.
Aust N Z J Public Health ; 45(3): 277-282, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33970509

RESUMO

OBJECTIVE: This study assessed the level of agreement, and predictors of agreement, between patient self-report and medical records for smoking status and alcohol consumption among patients attending one of four Aboriginal Community Controlled Health Service (ACCHSs). METHODS: A convenience sample of 110 ACCHS patients self-reported whether they were current smokers or currently consumed alcohol. ACCHS staff completed a medical record audit for corresponding items for each patient. The level of agreement was evaluated using the kappa statistic. Factors associated with levels of agreement were explored using logistic regression. RESULTS: The level of agreement between self-report and medical records was strong for smoking status (kappa=0.85; 95%CI: 0.75-0.96) and moderate for alcohol consumption (kappa=0.74; 95%CI: 0.60-0.88). None of the variables explored were significantly associated with levels of agreement for smoking status or alcohol consumption. CONCLUSIONS: Medical records showed good agreement with patient self-report for smoking and alcohol status and are a reliable means of identifying potentially at-risk ACCHS patients. Implications for public health: ACCHS medical records are accurate for identifying smoking and alcohol risk factors for their patients. However, strategies to increase documentation and reduce missing data in the medical records are needed.


Assuntos
Consumo de Bebidas Alcoólicas/etnologia , Grupo com Ancestrais Oceânicos/estatística & dados numéricos , Serviços Preventivos de Saúde , Fumar/etnologia , Adolescente , Adulto , Idoso , Austrália/epidemiologia , Serviços de Saúde Comunitária , Feminino , Serviços de Saúde do Indígena , Humanos , Masculino , Auditoria Médica , Registros Médicos , Pessoa de Meia-Idade , Fatores de Risco , Autorrelato , Inquéritos e Questionários , Adulto Jovem
13.
Acta Med Port ; 34(3): 176-184, 2021 Mar 01.
Artigo em Português | MEDLINE | ID: mdl-33971114

RESUMO

INTRODUCTION: Syndromic surveillance allows early detection of changes in the population's morbidity pattern. The aim of this study is to evaluate the usefulness of indicators related to access to healthcare services, in COVID-19 surveillance. MATERIAL AND METHODS: A time series analysis was performed using the weekly incidence rate of COVID-19 in Mainland Portugal, between weeks 14/2020 (March 30 to April 5) and 25/2020 (June 15 to 21), and six indicators: 1) COVID-19 consultations in primary healthcare; 2) number of COVID-19 emergency department visits; 3) number of emergency department visits due to viral pneumonia; 4) number of hospitalizations due to viral pneumonia; 5) proportion of emergency department visits due to viral pneumonia; and 6) proportion of hospitalizations for viral pneumonia. Pearson correlation and cross-correlations were computed. RESULTS: A strong correlation was found between the weekly incidence rate of COVID-19 and all indicators. [(1) 0.76; (2) 0.82; (3) 0.77; (4) 0.84; (5) 0.86; e (6) 0.90]. Emergency department visits and hospitalizations for viral pneumonia detect variations in the frequency of the disease with a one week lag compared to the incidence rate of COVID-19, in one week. COVID-19 consultations in primary healthcare and emergency department visits trail behind the incidence rate of COVID-19, in one week. The proportion of viral pneumonias in emergency department visits, or hospitalizations, is temporally aligned with the weekly incidence rate of COVID-19. DISCUSSION: The delay found in the COVID-19 primary healthcare consultations and emergency department visits, may be related to changes in access to healthcare services and clinical coding. Emergency department visits and hospitalizations for viral pneumonia may be useful in the early detection of COVID-19. Viral pneumonia may have been coded as being of unknown origin. Future monitoring of these indicators is necessary to ascertain whether the incidence of COVID-19 is significantly influenced by changes in testing strategies. The indicators described in this study will be an asset for the optimization of testing strategies, allocation of healthcare resources to the communities that are most vulnerable to severe morbidity and assessing vaccination impact. As such, surveillance systems based on clinical data will be a valuable complementary tool to SINAVE. CONCLUSION: The indicators under analysis could be used regularly, with special attention to viral pneumonias, to detect outbreaks of COVID-19. Information on pneumonia of unknown etiology may be considered in the surveillance of COVID-19.


Assuntos
COVID-19/diagnóstico , Acesso aos Serviços de Saúde/estatística & dados numéricos , Registros Médicos/estatística & dados numéricos , Vigilância de Evento Sentinela , COVID-19/epidemiologia , Diagnóstico Precoce , Serviço Hospitalar de Emergência/estatística & dados numéricos , Registros de Saúde Pessoal , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Pneumonia Viral/epidemiologia , Portugal/epidemiologia , Fatores de Tempo
14.
Medicine (Baltimore) ; 100(18): e25841, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33950997

RESUMO

ABSTRACT: Palliative care has improved quality of end-of-life (EOL) care for patients with cancer, and these benefits may be extended to patients with other serious illnesses. EOL care quality for patients with home-based care is a critical problem for health care providers. We compare EOL quality care between patients with advanced illnesses receiving home-based care with and without palliative services.The medical records of deceased patients who received home-based care at a community teaching hospital in south Taiwan from January to December 2019 were collected retrospectively. We analyzed EOL care quality indicators during the last month of life.A total of 164 patients were included for analysis. Fifty-two (31.7%) received palliative services (HP group), and 112 (68.3%) did not receive palliative services (non-HP group). Regarding the quality indicators of EOL care, we discovered that a lower percentage of the HP group died in a hospital than did that of the non-HP group (34.6% vs 62.5%, P = .001) through univariate analysis. We found that the HP group had lower scores on the aggressiveness of EOL care than did the non-HP group (0.5 ±â€Š0.9 vs 1.0 ±â€Š1.0, P<.001). Furthermore, palliative services were a significant and negative factor of dying in a hospital after adjustment (OR = 0.13, 95%CI = 0.05-0.36, P < .001).For patients with advanced illnesses receiving home-based care, palliative services are associated with lower scores on the aggressiveness of EOL care and a reduced probability of dying in a hospital.


Assuntos
Estado Terminal/terapia , Serviços Hospitalares de Assistência Domiciliar/organização & administração , Cuidados Paliativos/organização & administração , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Assistência Terminal/organização & administração , Idoso , Idoso de 80 Anos ou mais , Estado Terminal/mortalidade , Feminino , Serviços Hospitalares de Assistência Domiciliar/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Comunitários/organização & administração , Hospitais Comunitários/estatística & dados numéricos , Hospitais de Ensino/organização & administração , Hospitais de Ensino/estatística & dados numéricos , Humanos , Masculino , Registros Médicos/estatística & dados numéricos , Cuidados Paliativos/métodos , Cuidados Paliativos/estatística & dados numéricos , Estudos Retrospectivos , Taiwan/epidemiologia , Assistência Terminal/métodos , Assistência Terminal/estatística & dados numéricos
15.
Enferm. glob ; 20(62): 426-452, abr. 2021. tab
Artigo em Espanhol | IBECS | ID: ibc-202238

RESUMO

OBJETIVO: Conocer las características del proceso de final de vida en un Hospital Comarcal, según los actores implicados, estableciendo los elementos de convergencia/divergencia en el proceso asistencial, toma de decisiones, información y conocimientos. MÉTODO: Estudio observacional, transversal, descriptivo, convergente y analítico de métodos mixtos y triangulación de datos. Se realizó sobre una muestra de 63 sujetos, de los que 25 fueron profesionales, 19 familiares cuidadores y 19 historias clínicas de pacientes fallecidos a lo largo de un año. RESULTADOS: La triangulación de datos muestra discrepancias entre familiares y profesionales de salud en cuanto a la calidad de la asistencia y la información facilitada. Destaca la falta de registro en las historias clínicas revisadas sobre aspectos del proceso asistencial relacionados con la toma de decisiones o la sedación terminal. CONCLUSIÓN: Este estudio proporciona una visión integrada sobre la atención sanitaria en el proceso de final de vida prestada en un Hospital Comarcal. Muestra áreas prioritarias de intervención, para mejorar la calidad de vida en este proceso, como son la implicación del paciente en la toma de decisiones, la cumplimentación adecuada en las historias clínicas y la formación de los profesionales


OBJECTIVE: To know the characteristics of the end-of-life process in a Regional Hospital, according to the actors involved, establishing convergence/divergence elements in care process, decision-making, information and knowledge. METHOD: Observational, cross-sectional, descriptive, convergent of mixed methods and data triangulation study. Carried out on a sample of 63 subjects, of which 25 were health professionals, 19 family caregivers and 19 medical records of patients who died in the course of a year. RESULTS: Data triangulation shows discrepancies between family members and health professionals regarding care quality and the information provided. The lack of documentation in medical records of care aspects related to decision-making or terminal sedation stands out. CONCLUSION: This study provides an integrated view of end-of-life care provided in a Regional Hospital, identifying priority areas of intervention in order to improve quality of life in this process, such as patient involvement in decision-making, appropriate completion of medical records and health professional training


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Tomada de Decisões , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Estudos Transversais , Pessoal de Saúde/estatística & dados numéricos , Registros Médicos/estatística & dados numéricos , Cuidadores/estatística & dados numéricos , Inquéritos e Questionários , Determinação de Necessidades de Cuidados de Saúde/estatística & dados numéricos , Papel do Profissional de Enfermagem/psicologia
16.
Stomatologiia (Mosk) ; 100(2): 12-17, 2021.
Artigo em Russo | MEDLINE | ID: mdl-33874654

RESUMO

The influence of the quality of registration of medical records in the provision of dental care to the possibility of objective evaluation of the quality of treatment in forensic examinations. The structure of complaints that became the basis for 432 patients' appeal to the court, the frequency of occurrence and the qualitative composition of questions to expert doctors are determined. It is proved, that the medical record of a dental patient is one of the main proofs in the judicial process when justifying the position of the parties: 81% of legislative examinations contained questions about compliance with clinical recommendations and treatment standards, and 69% about the presence of defects and shortcomings of treatment. Analysis of the quality 1530 of dental records in various regions of the Russian Federation showed that only 77.8±1.06% of the records contained a detailed description of the course of surgery, a description of additional diagnostic methods was present in 70.6±1.16%, and an informed consent to surgery in 15.3±0.91% of the records. Unqualified filling out of the medical record is currently regarded as poorly provided medical care so it is necessary to change the attitude of dentists to filling out medical documentation.


Assuntos
Documentação , Registros Médicos , Assistência Odontológica , Humanos , Federação Russa
17.
BMC Pediatr ; 21(1): 172, 2021 04 14.
Artigo em Inglês | MEDLINE | ID: mdl-33853569

RESUMO

BACKGROUND: Pediatric patients present to Emergency Departments (EDs) with a variety of medical conditions. An appreciation of the common presenting conditions can aid EDs in the provision of pediatric emergency care. In this study, we established the common pediatric diagnoses seen at the general EDs, with reference to a pediatric ED. METHODS: A retrospective review of medical records was performed for patients less than 16 years old at a pediatric ED and two general EDs from 1 January to 31 December 2018. Information including patient demographics, triage category, case type and diagnoses were collected. RESULTS: There were 159,040 pediatric attendances, of which 3477 (2.2%) were seen at the general EDs. Non-traumatic conditions were most prevalent at both general (N = 1933, 55.6%) and pediatric (N = 128,415, 82.5%) EDs. There was a higher proportion of trauma related conditions seen at the general EDs (N = 1544, 44.4%) compared to the pediatric ED (N = 27,148, 17.5%; p < 0.01). Across all EDs, upper respiratory tract infection, unspecified musculoskeletal pain and gastroenteritis were the three most common non-trauma related diagnoses, while fracture, wound and contusion were the three most common trauma related diagnoses. There was a greater proportion of emergent (P1) cases seen at the general EDs (N = 233, 6.7%) than the pediatric ED (N = 3821, 2.5%; p < 0.01). Respiratory conditions including bronchiolitis, asthma and bronchitis were the most common emergent (P1) diagnoses. CONCLUSIONS: The common diagnoses among pediatric attendances varied between pediatric and general EDs. Therefore, general EDs should focus their efforts on these common diagnoses, especially the emergent (P1) ones, so that they can enhance their preparedness and work towards providing quality pediatric emergency care.


Assuntos
Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Adolescente , Criança , Emergências , Humanos , Registros Médicos , Estudos Retrospectivos
18.
BMJ Open ; 11(4): e045053, 2021 04 09.
Artigo em Inglês | MEDLINE | ID: mdl-33837102

RESUMO

OBJECTIVES: To develop a model of in-hospital mortality using medical record front page (MRFP) data and assess its validity in case-mix standardisation by comparison with a model developed using the complete medical record data. DESIGN: A nationally representative retrospective study. SETTING: Representative hospitals in China, covering 161 hospitals in modelling cohort and 156 hospitals in validation cohort. PARTICIPANTS: Representative patients admitted for acute myocardial infarction. 8370 patients in modelling cohort and 9704 patients in validation cohort. PRIMARY OUTCOME MEASURES: In-hospital mortality, which was defined explicitly as death that occurred during hospitalisation, and the hospital-level risk standardised mortality rate (RSMR). RESULTS: A total of 14 variables were included in the model predicting in-hospital mortality based on MRFP data, with the area under receiver operating characteristic curve of 0.78 among modelling cohort and 0.79 among validation cohort. The median of absolute difference between the hospital RSMR predicted by hierarchical generalised linear models established based on MRFP data and complete medical record data, which was built as 'reference model', was 0.08% (10th and 90th percentiles: -1.8% and 1.6%). In the regression model comparing the RSMR between two models, the slope and intercept of the regression equation is 0.90 and 0.007 in modelling cohort, while 0.85 and 0.010 in validation cohort, which indicated that the evaluation capability from two models were very similar. CONCLUSIONS: The models based on MRFP data showed good discrimination and calibration capability, as well as similar risk prediction effect in comparison with the model based on complete medical record data, which proved that MRFP data could be suitable for risk adjustment in hospital performance measurement.


Assuntos
Infarto do Miocárdio , Risco Ajustado , China/epidemiologia , Mortalidade Hospitalar , Hospitais , Humanos , Registros Médicos , Estudos Retrospectivos
19.
BMJ Open ; 11(4): e042870, 2021 04 24.
Artigo em Inglês | MEDLINE | ID: mdl-33895712

RESUMO

OBJECTIVE: To assess the validity of the US Department of Health and Human Services (DHHS) definition of multimorbidity using International Classification of Diseases, ninth edition (ICD-9) codes from administrative data. DESIGN: Cross-sectional comparison of two ICD-9 billing code algorithms to data abstracted from medical records. SETTING: Olmsted County, Minnesota, USA. PARTICIPANTS: An age-stratified and sex-stratified random sample of 1509 persons ages 40-84 years old residing in Olmsted County on 31 December 2010. STUDY MEASURES: Seventeen chronic conditions identified by the US DHHS as important in studies of multimorbidity were identified through medical record review of each participant between 2006 and 2010. ICD-9 administrative billing codes corresponding to the 17 conditions were extracted using the Rochester Epidemiology Project records-linkage system. Persons were classified as having each condition using two algorithms: at least one code or at least two codes separated by more than 30 days. We compared the ICD-9 code algorithms with the diagnoses obtained through medical record review to identify persons with multimorbidity (defined as ≥2, ≥3 or ≥4 chronic conditions). RESULTS: Use of a single code to define each of the 17 chronic conditions resulted in sensitivity and positive predictive values (PPV) ≥70%, and in specificity and negative predictive values (NPV) ≥70% for identifying multimorbidity in the overall study population. PPV and sensitivity were highest in persons 65-84 years of age, whereas NPV and specificity were highest in persons 40-64 years. The results varied by condition, and by age and sex. The use of at least two codes reduced sensitivity, but increased specificity. CONCLUSIONS: The use of a single code to identify each of the 17 chronic conditions may be a simple and valid method to identify persons who meet the DHHS definition of multimorbidity in populations with similar demographic, socioeconomic, and health care characteristics.


Assuntos
Classificação Internacional de Doenças , Multimorbidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Estudos Transversais , Humanos , Registros Médicos , Pessoa de Meia-Idade , Minnesota/epidemiologia , Estados Unidos/epidemiologia , United States Dept. of Health and Human Services
20.
Medicina (Kaunas) ; 57(4)2021 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-33920921

RESUMO

Holistic and life-long medical surveillance is the core of personalised medicine and supports an optimal implementation of both preventive and curative healthcare. Personal medical records are only partially unified by hospital or general practitioner informatics systems, but only for citizens with long-term permanent residence. Otherwise, insight into the medical history of patients greatly depends on their medical archive and memory. Additionally, occupational exposure records are not combined with clinical or general practitioner records. Environmental exposure starts preconceptionally and continues during pregnancy by transplacental exposure. Antenatal exposure is partially dependent on parental lifestyle, residence and occupation. Newborn screening (NBS) is currently being performed in developed countries and includes testing for rare genetic, hormone-related, and metabolic conditions. Transplacental exposure to substances such as endocrine disruptors, air pollutants and drugs may have life-long health consequences. However, despite the recognised impact of transplacental exposure on the increased risk of metabolic syndrome, neurobehavioral disorders as well as immunodisturbances including allergy and infertility, not a single test within NBS is geared toward detecting biomarkers of exposure (xenobiotics or their metabolites, nutrients) or effect such as oestradiol, testosterone and cytokines, known for being associated with various health risks and disturbed by transplacental xenobiotic exposures. The outcomes of ongoing exposome projects might be exploited to this purpose. Developing and using a OneHealth Medical Record (OneHealthMR) may allow the incorporated chip to harvest information from different sources, with high integration added value for health prevention and care: environmental exposures, occupational health records as well as diagnostics of chronic diseases, allergies and medication usages, from birth and throughout life. Such a concept may present legal and ethical issues pertaining to personal data protection, requiring no significant investments and exploits available technologies and algorithms, putting emphasis on the prevention and integration of environmental exposure and health data.


Assuntos
Exposição Ambiental , Exposição Ocupacional , Feminino , Humanos , Recém-Nascido , Registros Médicos , Triagem Neonatal , Gravidez
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