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Rationale, aims and objectives Structuring the diagnostic section of the medical record ( MR) improves diagnosis and communication between doctors. However, little is known about the therapeutic section of the MR. The aim of this study was to gain insight into the extent to which MRs are structured for therapeutic information, to determine which therapeutic data registrars and clinical consultants consider should be recorded in the MR and to what extent registrars record this information themselves. Methods A multicentre observational study was carried out in the internal medicine outpatient clinics of five teaching hospitals in the Netherlands. Preformatted structure, importance and actual recording of therapeutic information was compared with a reference list of 35 therapeutic items based on the WHO Guide to Good Prescribing (e.g. drug name, indication for drug). Results The preformatted structure of four paper MRs and one electronic MR was assessed. Eight of the 35 therapeutic items were listed in the paper MRs and 18 items in the electronic MR. Registrars and consultants agreed on the importance of recording most of the therapeutic items in the MR, 25 and 27 out of the 35 items, respectively; however, registrars recorded only 11 of the 35 items in the paper MR and 20 of the 35 items in the electronic MR. Conclusions The structure and content of paper and electronic MRs are not adequate. While both registrars and consultants agree on the importance of recording therapeutic items in the MR, registrars fail to record most of this information in practice. The results of this study can be used as starting point for the discussion regarding the necessity of structured recording of therapeutic information in the MR and its possible benefits with regard to medication safety and training of the new generation of prescribers. [ABSTRACT FROM AUTHOR]

Rationale: Reflective portfolios have been widely trailed in vocational programmes for health sciences education. While not raised explicitly yet, there is recognition that an essential part of a portfolio may still be missing - that is the experience of theoretical and analytic questioning that should occur after reflection., Aims and Objectives: In this paper, we argue that portfolios require both reflective and reasoned components to provide a more complete range of educational experiences for postgraduate doctors in the pursuit of higher qualifications., Methods: We describe the differentiating features between the two components and conclude with some suggestions on how both reflective and reasoned components of portfolios may work synergistically through a series of case studies., Results: The reflective style of portfolio, which is in current use, has been widely accepted as a major advance in postgraduate medical education at all levels. It provides an effective vehicle for encouraging self-consideration and generalizability. It is an important adjunct where it functions as a personal development tool as well as a sophisticated log book. A reasoned or pedagogic element encourages more analytic activities: adding an additional component that can ground the portfolio in theory or research. The portfolio is then able to function in a range of academic spheres and provide a theoretical platform for the wide range of non-clinical empirical work undertaken in clinical settings. The addition of a reasoned component also increases the emphasis on the introduction of new concepts outside the sphere of the learner's experience., Conclusions: A portfolio containing both reflective and reasoned components is then able to function in a range of academic spheres and provide a theoretical platform for the wide range of non-clinical empirical work undertaken in clinical settings. In an iterative mode, such a portfolio element can support a forum for questioning established concepts within a pedagogical environment - the essence of evidence-based practice., (© 2010 Blackwell Publishing Ltd.)

Background Research indicates that multifaceted practice development (PD) interventions are more effective than single strategies. However, models of education in health care need to consider cost-effectiveness. Objectives This paper presents a research-based, PD theory called the Individual Practice Development Theory. It argues that programmes that use the Individual Practice Development Theory to tailor PD support to the learning needs of practitioners will result in more engagement in PD and will target PD resources efficiently. Methods The in-depth qualitative, multi-method realistic evaluation was of a multifaceted, organization-wide PD programme in one National Health Service Mental Health and Learning Disabilities Trust. Semi-structured interviews, practice observation and documentation audit were used to gather data from occupational therapists. Findings Results indicated that environmental contexts, particularly the support of the immediate team, and the participant's personal circumstances affected PD behaviour change. Six mechanisms acted as catalysts. These were: Building Confidence, Finding Flow, Accumulating Reward, Conferring with Others, Constructing Knowledge Know-how and Channelling Time. Four stages of PD characterized as: 'In the Hangar', 'On the Runway', 'Take-off' and 'In the Air' were identified. The research also illustrated the interconnectivity between outcome levels, contextual circumstances and activating mechanisms. Discussion The findings suggested that PD interventions need to be more individually tailored to achieve optimum learning outcomes. The identification of four discernable stages permits rapid understanding of PD support needs in order to focus PD support. Conclusion With a systematic and individualized approach to PD in health care, more target PD supports can be put in place. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Sharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care‐plan in the acute care setting. Method: We carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4‐week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses. Results: Patients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient‐doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the 'right' amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time‐consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles. Conclusions: A summary record could empower patients and improve patient‐doctor communication but would require additional clinician and administrative time. [ABSTRACT FROM AUTHOR]

Background and aims: Current guidance advises that at least 90% of anterior cruciate ligament reconstructions are performed as day‐case operations. Same‐day surgery rates achieved by surgical units have significant clinical and financial implications. The primary aim of this multi‐centre study was to determine the rate of admission and causes for admissions in patients undergoing anterior cruciate ligament reconstruction. Method: Patient documentations were studied for those who underwent an elective anterior cruciate ligament reconstruction between January 2015 and April 2019. Contributing factors related to admission length were investigated and included patient age, gender, body mass index (BMI), operating surgeon, operating hospital, American Society of Anaesthesiology (ASA) grade, and position of the patient on the operating list. Both univariate and multivariate analysis were conducted using the STATA/IC 16.1 statistical package. Results: The day surgery rate of anterior cruciate ligament reconstructions were 52% (50/95). Patients positioned later on the operating list were more likely to be admitted post‐operatively (OR, 4.49; P =.002; 95% CI, 1.72‐11.69) and this was the only factor associated with admission. A large majority of admitted patients (95.6%) were admitted without a clinical cause and were otherwise safe for same‐day discharge. Conclusions: The day surgery rate for ACL reconstruction remains low, despite an extremely low complication rate. Reconfiguration of the operating lists and positioning anterior cruciate ligament reconstructions earlier in the day will likely increase the same‐day discharge rate and reduce associated costs. [ABSTRACT FROM AUTHOR]

Rationale and objective: The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. Method: One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4‐point Likert‐type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision. Results: The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. Conclusions: In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations. [ABSTRACT FROM AUTHOR]

Rationale/aim: Medication administration is a complex and time‐consuming task in residential aged care facilities (RACFs). Understanding the time associated with each administration step may help identify opportunities to optimize medication management in RACFs. This study aimed to investigate the time taken to administer medications to residents, including those with complex care needs such as cognitive impairment and swallowing difficulties. Method: A time‐and‐motion study was conducted in three South Australian RACFs. A representative sample of 57 scheduled medication administration rounds in 14 units were observed by a single investigator. The rounds were sampled to include different times of day, memory support units for residents living with dementia and standard units, and medication administration by registered and enrolled nurses. Medications were administered from pre‐prepared medication strip packaging. The validated Work Observation Method By Activity Timing (WOMBAT) software was used to record observations. Results: Thirty nurses were observed. The average time spent on scheduled medication administration rounds was 5.2 h/unit of average 22 residents/day. The breakfast medication round had the longest duration (1.92 h/unit). Resident preparation, medication preparation and provision, documentation, transit, communication, and cleaning took an average of 5 minutes per resident per round. Medication preparation and provision comprised 60% of overall medication round time and took significantly longer in memory support than in standard units (66 vs 49 seconds per resident per round for preparation, 79 vs 58 for provision; P <.001 for both). Almost half (42%) of tablets/capsules were crushed in memory support units. The time taken for medication administration was not significantly different among registered and enrolled nurses. Conclusions: Nurses took an average of 5 minutes to administer medications per resident per medication round. Medication administration in memory support units took an additional minute per resident per round, with almost half of tablets and capsules needing to be crushed. [ABSTRACT FROM AUTHOR]

Rationale: In 2015, Queen's University embarked on an institution‐wide transition to a competency‐based medical education (CBME) curriculum for all 29 postgraduate medical education programmes. On 1 July 2017, this goal was accomplished. With this mass transition came the requirement to assess the efficacy of implementation through a programme evaluation process, which included the use of outcome harvesting (Wilson‐Grau). Outcome harvesting identified the intended and unintended outcomes of CBME implementation, which helped us understand how the intervention was achieved and how the relationship between behaviours and stakeholders contributed to the successful transition. Methods: A systematic approach to document analysis was used to categorize the eight identified areas of implementation: governance, scholarship, faculty development, resident leadership, curriculum, assessment, communications, and technology. Documents (N = 443) were organized per project area and then coded thematically. Documents were then categorized for attribution to outcomes using the outcome harvesting approach. Outcomes were validated via interrater reliability and substantiated by stakeholders to verify accuracy of formulation and plausibility of its influence on the outcome. Results: The harvest produced 38 outcomes, either intended or unintended, that can be attributed to CBME implementation at Queen's University. Conclusion: Using outcome harvesting to assess the efficacy of CBME implementation produced a robust set of themes and resultant outcomes that can be categorized as requirements for success of implementation of any curricular innovation. Emergent themes included collaboration, community of practice, and stakeholder commitment. More unique observations noted through the harvest process included new policy development, creation of learner ownership, and an increase in the output of scholarly activity involving CBME. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Providing high‐quality primary care in patient‐centred medical homes (PCMHa) requires competencies that can only be provided by interprofessional (IP) education. The benefits of collaborative training have been documented for learners, but less is known about the perceptions of the clinical professionals who train the learners or the patients receiving IP primary care. This investigation compared stakeholder attitudes about IP education, training, and providing collaborative care prior to developing a new IP training programme. Methods: We conducted five focus groups at a large general internal medicine training practice. Learner and faculty groups included participants from medicine, psychology, pharmacy, and physician assistant professions; three patient groups were held to obtain perspectives on receiving health care from IP trainees. We used inductive analysis to identify themes across the three stakeholder groups. Results: We identified seven convergent themes across all three stakeholder groups: (a) team engagement, (b) technology in care delivery, (c) cost of care, (d) involving patients in learning, (e) time constraints, (f) scope of practice, and (g) autonomy/interdependence. Each group emphasized the need to define and communicate team members' roles. Learners anticipated high‐quality IP interactions, and patients noted the benefits of receiving care from well‐supervised trainees. Faculty struggled to navigate the training needs of diverse learner groups and to integrate PCMH mandates focused on documentation with authentic patient‐centred care. Conclusions: This is the first reported data comparing perceptions about IP training and care across these three stakeholder groups. Results suggest the need to clarify scope of practice, define professional roles, and bridge gaps between teaching PCMH principles and subsequently providing high‐quality health care. Results inform faculty development needs in learning ways to train learners across professions and outline ways to structure interactions with patients. [ABSTRACT FROM AUTHOR]

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Abstract: Rationale, aims and objectives: Care quality is a primary concern in health field. In France, the care practice report card (CPRC) is compulsory for practitioners. It is the first step towards the culture of excellence. In this context, practitioners have to assess and improve their practices. Competent authorities define registries as reliable sources for CPRC. The first aim of this work is to describe how we designed and built a universally transposable CPRC model based on an Utstein‐style cardiac arrest registry. The second aim is to measure the adherence of practitioners to this approach and to show how such a tool can be used in real situation. Methods: Our report card is adapted from in‐hospital CA care quality and safety indicators. We built a 2‐section grid. The first part described the quality and completeness of the analysed data. The second part distinguished medical and traumatic CA and assesses care practices. We analysed the practitioners' adherence thanks to a satisfaction survey. Finally, we presented a CPRC case study. Results: This tool was tested in 92 centres gathering 8433 patients. The satisfaction survey showed that this CPRC was well accepted by emergency professionals. We presented an implementation example of this tool in a centre in real‐life situation. Conclusions: We designed and implemented a fully automated CPRC tool routinely usable for Utstein‐style CA registries. This CPRC is easily transferable in all other Utstein CA registries. The debriefing report source codes are freely distributed upon request. This tool enables the care assessment and improvement. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: This study aimed to assess the feasibility, benefits, and challenges of routine outcome monitoring (ROM) in a public mental health centre in Israel. This is the first initiation of ROM implementation in a setting of a large psychiatric hospital, affiliated with the largest health maintenance organization in Israel, Clalit Health Services. Methods: Four ambulatory units were invited to participate in the implementation of ROM. Prior to initiation of recruitment, staff meetings were held and broad descriptions of current knowledge regarding benefits and challenges were discussed. Upon initiation of recruitment, patients completed outcome and process questionnaires during each session, and reports of patients' progress were sent to therapists soon after sessions ended. Results: One hundred sixty‐three patients were invited to participate in measurement and feedback of therapy outcomes. Overall, 101 patients and 32 therapists agreed and actively participated in the implementation phase of ROM, producing 535 evaluated measurements and reports. Clinical, methodological, legal, administrative, and ethical aspects of the implementation were encountered and documented throughout the implementation process. Conclusions: Medical confidentiality issues, as well as the multidisciplinary nature of hospital staff work, serve as central and unique challenges for incorporating ROM in a public psychiatric hospital. Other challenges that were previously reported in other implementation studies were also encountered and included therapist overload and objections, attrition, and the need for organizational support. Recommendations for future pioneering efforts for ROM implementation in large psychiatric facilities are discussed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Complex chronic diseases are a challenge for the current configuration of health services. Case management is a service frequently provided for people with chronic conditions, and despite its effectiveness in many outcomes, such as mortality or readmissions, uncertainty remains about the most effective form of team organization, structures and the nature of the interventions. Many processes and outcomes of case management for people with complex chronic conditions cannot be addressed with the information provided by electronic clinical records. Registries are frequently used to deal with this weakness. The aim of this study was to generate a registry-based information system of patients receiving case management to identify their clinical characteristics, their context of care, events identified during their follow-up, interventions developed by case managers and services used. Methods The study was divided into three phases, covering the detection of information needs, the design and its implementation in the health care system, using literature review and expert consensus methods to select variables that would be included in the registry. Results A total of 102 variables representing structure, processes and outcomes of case management were selected for their inclusion in the registry after the consensus phase. A web-based registry with modular and layered architecture was designed. The framework follows a pattern based on the model-view-controller approach. In its first 6 months after the implementation, 102 case managers have introduced an average number of 6.49 patients each one. Conclusions The registry permits a complete and in-depth analysis of the characteristics of the patients who receive case management, the interventions delivered and some major outcomes as mortality, readmissions or adverse events. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Obesity is significantly underdiagnosed and undertreated in primary care settings. The purpose of this clinical practice change project was to increase provider adherence to national clinical practice guidelines for the diagnosis and treatment of obesity in adults. Methods Based upon the National Institutes of Health guidelines for the diagnosis and treatment of obesity, a clinical change project was implemented. Guided by the theory of planned behaviour, the Provider and Healthcare team Adherence to Treatment Guidelines ( PHAT- G) intervention includes education sessions, additional provider resources for patient education, a provider reminder system and provider feedback. Results Primary care providers did not significantly increase on documentation of diagnosis and planned management of obesity for patients with body mass index ( BMI) greater than or equal to 30. Medical assistants increased recording of height, weight and BMI in the patient record by 13%, which was significant. Conclusions Documentation of accurate BMI should lead to diagnosis of appropriate weight category and subsequent care planning. Future studies will examine barriers to adherence to clinical practice guidelines for obesity. Interventions are needed that include inter-professional team members and may be more successful if delivered separately from routine primary care visits. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To evaluate asthma management and control in primary care clinics so as to design improvements based on guideline-directed outcomes. Methods In this study, all medical records of asthma-diagnosed patients (children as well as adults, entire lifespan, asthma-related visits or not) were retrospectively reviewed as a basis for assessing the level of guideline adherence and asthma control. Six primary health care clinics were visited in the Dr Kenneth Kaunda Municipal District, Potchefstroom, South Africa during May to July 2008, 2009 and 2010. Results A total of 323 asthma patient records were reviewed over the three time slots, resulting in 125, 87, and 111 patients respectively. A suboptimal clinical asthma control picture, with a mere 16% (n = 20) of females and 2% (n = 3) of males with Peak Expiratory Flow (PEF) percentages above 60%, were observed in the initial assessment. Improvement in control was observed during the following time slot, but with an end result in 2010 of no PEF percentages above 60% for males and only 9% (n = 7) for females. Conclusion Over all three of the data collection periods adherence to effectively applied management of asthma guidelines proved to be below the minimum recommended clinical evaluation work-up as set out by the Expert Panel Report 3 (EPR3) of the National Asthma Education and Prevention Program (NAEPP). Applying a greater focus on essential outcomes through different disease management documents resulted in an improved quality of managed care, but still requires dedicated and continuous education and motivation. (NWU-0052-08-A5) [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Extraction of prescribing data from medical records is a common, albeit flawed, research method. Yet little is known about the processes that result in those data. This study explores the creation and use of prescribing documentation in the medical record, from the perspective of the hospital doctors who both create and use it. Methods Thirty-six hospital doctors were purposively selected for qualitative interviews, giving a maximum variability sample of grades of doctors across the range of major medical specialty areas and medical teams at a large teaching hospital in England. Results The findings suggest a number of reasons why hospital doctors fail to record prescribing decisions in the medical record. There was no set standard, record keeping was not formally taught and the hurried environment of the ward gave little time for documentation. The doctors also acknowledged that there was no need for completeness, as colleagues would be able to ‘fill in the gaps’ via an inferential process. Assumptions were made and although this was not seen as ideal, it was recognized as necessary if work was to be done efficiently. Conclusion These results reinforce the suggestion that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge. This has profound implications for those without that insider knowledge who are using medical records for research purposes. Funding This work was funded by a North West Regional National Health Service Postdoctoral Fellowship. [ABSTRACT FROM AUTHOR]