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477 records – page 1 of 48.

Accidental deaths and suicides in southwest Alaska: actual versus official numbers.

https://arctichealth.org/en/permalink/ahliterature3687
Source
Alaska Med. 1988 Mar-Apr;30(2):45-52
Publication Type
Article

Accidental falls and related fractures in 65-74 year olds: a retrospective study of 332 patients.

https://arctichealth.org/en/permalink/ahliterature198241
Source
Acta Orthop Scand. 2000 Apr;71(2):175-9
Publication Type
Article
Date
Apr-2000
Author
E. Nordell
G B Jarnlo
C. Jetsén
L. Nordström
K G Thorngren
Author Affiliation
Department of Orthopedics, Lund University Hospital, Sweden. eva.nordell@ort.lu.se
Source
Acta Orthop Scand. 2000 Apr;71(2):175-9
Date
Apr-2000
Language
English
Publication Type
Article
Keywords
Accidental Falls - prevention & control - statistics & numerical data
Activities of Daily Living
Age Distribution
Age Factors
Aged
Documentation
Emergency Service, Hospital - utilization
Female
Fractures, Bone - epidemiology - etiology - prevention & control
Geriatric Assessment
Humans
Male
Population Surveillance
Postural Balance
Referral and Consultation
Registries
Retrospective Studies
Risk factors
Sex Distribution
Sweden - epidemiology
Abstract
We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.
PubMed ID
10852324 View in PubMed
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Accuracy and quality in the nursing documentation of pressure ulcers: a comparison of record content and patient examination.

https://arctichealth.org/en/permalink/ahliterature77064
Source
J Wound Ostomy Continence Nurs. 2004 Nov-Dec;31(6):328-35
Publication Type
Article
Author
Gunningberg Lena
Ehrenberg Anna
Author Affiliation
Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden. lena.gunningberg@akademiska.se
Source
J Wound Ostomy Continence Nurs. 2004 Nov-Dec;31(6):328-35
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Cross-Sectional Studies
Documentation - standards
Female
Health services needs and demand
Hospitals, University
Humans
Male
Middle Aged
Nursing Assessment - standards
Nursing Audit
Nursing Evaluation Research
Nursing Records - standards
Observer Variation
Physical Examination - nursing - standards
Practice Guidelines
Pressure Ulcer - diagnosis - epidemiology - nursing
Prevalence
Retrospective Studies
Risk assessment
Severity of Illness Index
Sweden - epidemiology
Abstract
OBJECTIVE: To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting. DESIGN: A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients. SETTING AND SUBJECTS: All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital. INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation. METHODS: All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments. RESULTS: The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor. CONCLUSIONS: Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.
PubMed ID
15867708 View in PubMed
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Accuracy in documentation of peripheral venous catheters in paediatric care: an intervention study in electronic patient records.

https://arctichealth.org/en/permalink/ahliterature128012
Source
J Clin Nurs. 2012 May;21(9-10):1339-44
Publication Type
Article
Date
May-2012
Author
Ulrika Förberg
Eva Johansson
Britt-Marie Ygge
Lars Wallin
Anna Ehrenberg
Author Affiliation
Department of Women's and Children's Health, Karolinska Institutet, Stockholm and School of Health and Social Studies, Dalarna University, Falun, Sweden. ulrika.forberg@karolinska.se
Source
J Clin Nurs. 2012 May;21(9-10):1339-44
Date
May-2012
Language
English
Publication Type
Article
Keywords
Catheters
Child
Documentation
Electronic Health Records
Humans
Pediatrics
Sweden
Abstract
The aim of this study is to compare the accuracy and completeness in the recording of peripheral venous catheters before and after implementing a template in the electronic patient record in paediatric care.
As a basis for quality improvement and research purposes and to ensure patient safety, accurate clinical data need to be easily accessible in patient records. Several studies have concluded that the relation between performed care and what is documented in patient records is poor.
Before and after study.
The study took place at a large paediatric university hospital in Sweden. Inclusion criteria were patients who were admitted to one of the included wards, had one or several peripheral venous catheters and were available at the ward at the time for data collection. Data were collected by observations and record audits before and then four and 10 months after the introduction of a template for recording peripheral venous catheters in a structured and standardised way.
A significant increase in peripheral venous catheters with complete recording was observed after as compared with before the intervention. The percentage of peripheral venous catheters with recording of any kind was relatively stable (85-93%). The overall recording of peripheral venous catheters insertion did not improve, but there was an increase in the recording of side and size after the intervention. One of the 22 complications observed before the intervention was documented and none of the complications (n = 17 and n = 9) after.
The electronic patient record did not provide accurate data on peripheral venous catheters in paediatric care neither before nor after the intervention.
Further efforts to increase the documentation of catheter-related complications are needed. Integrated decision support systems in electronic patient records that remind nurses to inspect peripheral venous catheters regularly could be one solution.
PubMed ID
22243530 View in PubMed
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[A conflict between physicians and nurses about the drug lists. Please, do not disturb--the drug documentation is going on].

https://arctichealth.org/en/permalink/ahliterature205186
Source
Lakartidningen. 1998 Jun 3;95(23):2728-32
Publication Type
Article
Date
Jun-3-1998

The Addiction Research Foundation documentation service--an example of a specialized information program.

https://arctichealth.org/en/permalink/ahliterature252323
Source
Drug Inf J. 1975 May-Sep;9(2-3):192-4
Publication Type
Article

[Administration of medications. Joint charts for prescription--transcription and dispensing errors].

https://arctichealth.org/en/permalink/ahliterature178572
Source
Ugeskr Laeger. 2004 Aug 9;166(33):2800-3
Publication Type
Article
Date
Aug-9-2004
Author
Henning K Nielsen
Maren-Lis Larsen
Jette Ratchke
Birgit Svendsen
Niels Obel
Birte Hansen
Author Affiliation
Randers Centralsygehus, Medicinsk Afdeling. HKN@rc.aaa.dk
Source
Ugeskr Laeger. 2004 Aug 9;166(33):2800-3
Date
Aug-9-2004
Language
Danish
Publication Type
Article
Keywords
Denmark
Documentation - standards
Drug Prescriptions - standards
Humans
Medication Errors - prevention & control
Medication Systems, Hospital - standards
Safety
Software
Notes
Comment In: Ugeskr Laeger. 2004 Sep 6;166(37):321915384381
PubMed ID
15344860 View in PubMed
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Admission medical records made at night time have the same quality as day and evening time records.

https://arctichealth.org/en/permalink/ahliterature262724
Source
Dan Med J. 2014 Jul;61(7):A4868
Publication Type
Article
Date
Jul-2014
Author
Ilda Amirian
Jacob F Mortensen
Jacob Rosenberg
Ismail Gögenur
Source
Dan Med J. 2014 Jul;61(7):A4868
Date
Jul-2014
Language
English
Publication Type
Article
Keywords
Aged
Appendicitis - diagnosis
Denmark
Documentation - standards
Female
Gallstones - diagnosis
Gastrointestinal Hemorrhage - diagnosis
Humans
Intestinal Obstruction - diagnosis
Male
Medical Records - standards
Patient Admission
Quality Assurance, Health Care
Quality Control
Time Factors
Abstract
A thorough and accurate admission medical record is an important tool in ensuring patient safety during the hospital stay. Surgeons' performance might be affected during night shifts due to sleep deprivation. The aim of the study was to assess the quality of admission medical records during day, evening and night time.
A total of 1,000 admission medical records were collected from 2009 to 2013 based equally on four diagnoses: mechanical bowel obstruction, appendicitis, gallstone disease and gastrointestinal bleeding. The records were reviewed for errors by a pre-defined checklist based on Danish standards for admission medical records. The time of dictation for the medical record was registered.
A total of 1,183 errors were found in 778 admission medical records made during day- and evening time, and 322 errors in 222 admission medical records from night time shifts. No significant overall difference in error was found in the admission medical records when day and evening values were compared to night values. Subgroup analyses made for all four diagnoses showed no difference in day and evening values compared with night time values.
Night time deterioration was not seen in the quality of the medical records.
PubMed ID
25123118 View in PubMed
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Advancing nursing documentation--an intervention study using patients with leg ulcer as an example.

https://arctichealth.org/en/permalink/ahliterature150933
Source
Int J Med Inform. 2009 Sep;78(9):605-17
Publication Type
Article
Date
Sep-2009
Author
Eva Törnvall
Lis Karin Wahren
Susan Wilhelmsson
Author Affiliation
Department of Social and Welfare Studies, Faculty of Health Sciences, University of Linköping, Campus Norköping, SE 60174 Norrköping, Sweden. evato@isv.liu.se
Source
Int J Med Inform. 2009 Sep;78(9):605-17
Date
Sep-2009
Language
English
Publication Type
Article
Keywords
Documentation - methods
Humans
Leg Ulcer - epidemiology - nursing
Medical Records Systems, Computerized
Nurses - statistics & numerical data
Sweden - epidemiology
Treatment Outcome
User-Computer Interface
Abstract
The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses' experiences of documentation.
This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n=102 and n=92, respectively] were carried out and 126 district nurses answered questionnaires pre-intervention and 83 post-intervention.
The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses' opinions. Furthermore, the district nurses' self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses' experiences of documentation in general between the two groups.
Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.
PubMed ID
19447071 View in PubMed
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477 records – page 1 of 48.