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Objectives: This study aimed to evaluate the appropriateness of the emergency referrals made by primary care clinicians and determine the factors contributing to inappropriate referrals. Methods: This crosssectional study utilises referral notes review between October 2019 and March 2020. Patients referred to Khawla Hospital's emergency department by a primary care clinician in Muscat Governorate were randomly selected; their referral notes were reviewed by five family physicians. The appropriateness of the referrals was evaluated according to the primary care referral protocol. Any referral that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified, and the factors contributing to inappropriate referral were determined using multivariable logistic regression. Results: In total, 591 referrals were reviewed; 354 (59.9%) of them were classified as inappropriate due to inadequate medical notes (291, 82.2%), lack of provisional diagnosis (176, 49.7%), misdirected to a non-concerned emergency (30, 8.4%) or misclassification of urgency (107 [30.2%] were classified as urgent and 45 [12.7%] as routine). After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines and lack of expertise were found to be strong determinants of inappropriate referral, with an odds ratio of 62.52 (95% confidence interval [CI]: 32.04-121.96), 2.88 (95% CI: 1.40-5.92) and 9.37 (95% CI: 4.09-21.43), respectively. Conclusion: While most of the referrals required emergency management, the majority were inappropriate, mainly due to insufficient clinical documentation. Inadequate clinical notes and lack of national guidelines and expertise were found to be strong predictors of inappropriate emergency referrals. [ABSTRACT FROM AUTHOR]

Background: Effective referral of maternity cases, which cannot be managed at the primary healthcare level, with detailed referral forms is important for reducing possible delays in the provision of higher-level healthcare. This is the first study to audit documentation or referral forms that accompany referred maternity cases to a referral hospital in the northern region of Ghana.Materials and Methods: This study employed an explanatory sequential mixed-method design, starting with a quantitative review of referral forms that accompanied all patients referred to four units (antenatal, antenatal emergency, labour and neonatal intensive care) of a referral hospital in northern Ghana. In-depth interviews were held with the heads of the four units afterwards. Descriptive statistics were computed for the quantitative data. The qualitative data was subjected to content analysis. Integration of the data occurred at the data interpretation/discussion level.Results: A total of 217 referral forms were analysed. Nearly half of the cases were referred from the Tamale Metropolis (46.5%) and 83.9% were referred for advanced care, whilst 8.3% were referred due to a lack of medical logistics and equipment such as oxygen and skilled personnel (6%). Completion rates of the referral forms were as follows: < 50% completion (n = 81; 37.3%), 50-75% completion (n = 112; 51.6%) above 75% completion (n = 24; 11.1%). Some of the handwriting were not legible and were quite difficult to read. The key informants stated that incomplete forms sometimes delay treatment. The head of the antenatal care unit at the referral hospital suggested professional development sessions as a strategy for supporting clinicians to fill the forms as expected.Conclusion: The Ghana Health Service should conduct regular audits, develop job aides and provide incentives for health professionals who accurately complete referral forms. Completing forms and digitizing health records can help ensure further efficiencies in the health information system and sustain good maternity referral documentation practices. [ABSTRACT FROM AUTHOR]

With the benefit of an anthropological attention to the importance of 'things' and the relations between ourselves and things ('artefacts'), this paper gives attention to the Social Work File. Despite the rise of electronic recording, social work archives remain full of thousands of files that are increasingly accessed, especially by those who have been in care, and physical file-keeping remains a regular feature of practice. There is already a body of literature relating to the information in social work files, however this paper shifts the focus from this to the nature and role of the File itself. 'Hidden in plain sight' but laden with meaning and capacity, I identify the little we know already about the file. The various ways files and their authors and subjects, can interact are explored together with the file's symbolic properties and the power held by the file's owner, and the ability of the file to 'other' its subject. Whilst we understand that the practice shapes the file, how might the file shape practice? [ABSTRACT FROM AUTHOR]

Background: The changes observed in nursing documentation prompted a historical study on the evolution of nursing records between 1958, when the Ministry of Health and Assistance was created, and 1998, when the Ordem dos Enfermeiros (Portuguese Nursing and Midwifery Regulator) was established. Thus, the analysis of publications on nursing records in Portuguese journals during this period was considered relevant. Objective: To identify and analyze the scientific production on nursing records published in Portuguese nursing journals between 1958 and 1998. Methodology: A bibliometric study was conducted by consulting 504 Portuguese nursing journals published between 1958 and 1998, using descriptors and inclusion criteria. Results: A final sample of 22 articles related to different aspects of nursing records was obtained. Conclusion: Nursing records have been a publication subject in Portuguese journals since 1984. The number of publications increased as changes occurred in the nursing profession. Nursing records have accompanied the nursing career’s professional reconfiguration and are essential for the profession’s autonomy. [ABSTRACT FROM AUTHOR]

In family settings stories, photographs and memory objects support narratives of identity and belonging. Such resources are often missing for people who were in care as children. As a result, they may be unable to fill gaps in their memories or answer simple questions about their early lives. In these circumstances, they turn to the records created about them by social workers and care providers to reconstruct personal histories. Research suggests that thousands of requests to view records for this purpose are made each year in England under the subject access provisions of data protection legislation. This article reports the findings of MIRRA, a participatory research project on the memory and identity dimensions of social care recordkeeping. Drawing on data collected during interviews and focus groups with adult care leavers, the study explores the motives and experiences of care‐experienced people who access their records in England. Findings show the practical and cultural challenges they face when doing so and the resulting impacts on well‐being. The study suggests that the development of person‐centred approaches to recordkeeping in social work, which focus on the perspectives and experiences of the individual, could better support the lifelong memory and identity needs of care‐experienced people. [ABSTRACT FROM AUTHOR]

The Documentation Center of the Anastasio de Gracia-FITEL Foundation is the depository of the Archive of the Federation of Industry, Construction and Agri-Food of the General Union of Workers (UGT-FICA) Among the documentation of this entity, the photographic archives of the press departments of the former sectoral federations of UGT: about 30,000 images that reflect the evolution of Spanish work since 1977. Funds that can be analyzed and studied from the point of view of its content or form. It is in this last aspect in which this study is centered, in relation to the authorship of the image. [ABSTRACT FROM AUTHOR]

Recently in psychological science and many related fields, a surprisingly large amount of experiments could not be replicated by independent researchers. A nonreplication could indicate that a previous finding might have been a false positive statistical result and the effect does not exist. However, it could also mean that a specific detail of the experimental procedure is essential for the effect to emerge, which might not have been included in the replication attempt. Therefore any replication attempt that does not replicate the original effect is most informative when the original procedure is closely adhered to. One proposed solution to facilitate the empirical reproducibility of the experimental procedures in psychology is to upload the experimental script and materials to a public repository. However, we believe that merely providing the materials of an experimental procedure is not sufficient, as many software solutions are not freely available, software solutions might change, and it is time consuming to set up the procedure. We argue that there is a simple solution to these problems when an experiment is conducted using computers: recording an example procedure with a screen capture software and providing the video in an online repository. We therefore provide a brief tutorial on screen recordings using an open source screen recording software. With this information, individual researchers should be able to record their experimental procedures and we hope to facilitate the use of screen recordings in computer assisted data collection procedures. [ABSTRACT FROM AUTHOR]

An examination of the cruciality of careful documentation when treating patients. [ABSTRACT FROM AUTHOR]

Here we consider the record data from the two-parameter of bathtub-shaped distribution. First, we develop simplified forms for the single moments, variances and covariance of records. These distributional properties are quite useful in obtaining the best linear unbiased estimators of the location and scale parameters which can be included in the model. The estimation of the unknown shape parameters and prediction of the future unobserved records based on some observed ones are discussed. Frequentist and Bayesian analyses are adopted for conducting the estimation and prediction problems. The likelihood method, moment based method, bootstrap methods as well as the Bayesian sampling techniques are applied for the inference problems. The point predictors and credible intervals of future record values based on an informative set of records can be developed. Monte Carlo simulations are performed to compare the so developed methods and one real data set is analyzed for illustrative purposes. [ABSTRACT FROM AUTHOR]

The purpose of this article is twofold. Firstly, to highlight that different types of document formats are proliferating and are constantly changing the ways we create, store, access and preserve records. It focuses on understanding the various ways records managers interpret and behave towards the different types of document formats. The second purpose of this article is to explore the repercussions of the behavioural patterns of employees and how the changing types of document formats impact on the management of corporate records and information. The main approach of the article is a literature review, although observations made from different contexts of records management, teaching workshops and experience were also included to help with the discussions. The article identifies that specific types of formats can be clearly conceptualised when format is viewed in terms of a document, a file or as information. The study also found that people within the organisation exhibit different types of behaviour patterns that can impact on the ways these documents, files and information format are managed in the organisation. Employees' behaviour patterns have implementations for the various information and records management processes in that when documents are not created in the required document format using the right software application, records cannot be accessed and used for its intended purposes. [ABSTRACT FROM AUTHOR]

Collections care describes actions taken to prevent or limit the deterioration of moveable cultural heritage and 'collections care documentation' (CCD) refers to the recording and retention of information relating to those activities. This paper describes the findings of a survey and targeted interviews with staff from a number of U.K. museums, archives and libraries. The results suggest that, while there is much good practice, some organisations face difficulties instituting a framework for CCD which covers all their activities effectively. Large and small organisations have varying challenges to face; the former with specialist staff working in separate departments and the latter with staff who carry out activities relating to preventive conservation but who may not have specialist knowledge. An efficient documentation structure, which is resilient and relevant to the organisation, can support and improve communication as well as raise awareness of the reasons for and methods of preventive conservation. This paper looks at the reasons why even basic practices can sometimes be difficult to achieve and presents ideas for identifying and overcoming barriers. As preventive conservators argue that specified actions influence the long-term sustainability of collections the evidence that allows verification those claims needs to be retained. In order to do this, a greater focus on what data to collect and why will enable the sector to align CCD with specific research questions. [ABSTRACT FROM AUTHOR]

The purpose of this review article is to discuss the development and associated estimation of uncertainties in the global and hemispheric surface temperature records. The review begins by detailing the groups that produce surface temperature datasets. After discussing the reasons for similarities and differences between the various products, the main issues that must be addressed when deriving accurate estimates, particularly for hemispheric and global averages, are then considered. These issues are discussed in the order of their importance for temperature records at these spatial scales: biases in SST data, particularly before the 1940s; the exposure of land-based thermometers before the development of louvred screens in the late 19th century; and urbanization effects in some regions in recent decades. The homogeneity of land-based records is also discussed; however, at these large scales it is relatively unimportant. The article concludes by illustrating hemispheric and global temperature records from the four groups that produce series in near-real time. [ABSTRACT FROM AUTHOR]

Abstract: Boundary work refers to the strategies deployed by professionals in the arenas of the public, the law and the workplace to define and defend jurisdictional authority. Little attention has been directed to the role of documents in negotiating professional claims. While boundary work over induced abortion has been extensively documented, few studies have examined jurisdictional disputes over the treatment of abortion complications, or post-abortion care (PAC). This study explores how medical providers deploy medical records in boundary work over the treatment of complications of spontaneous and induced abortion in Senegal, where induced abortion is prohibited under any circumstance. Findings are based on an institutional ethnography of Senegal's national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included in-depth interviews with 36 health care professionals, observation of PAC services at three hospitals, a review of abortion records at each hospital, and a case review of illegal abortions prosecuted by the state. Findings show that health providers produce a particular account of the type of abortion treated through a series of practices such as the patient interview and the clinical exam. Providers obscure induced abortion in medical documents in three ways: the use of terminology that does not differentiate between induced and spontaneous abortion in PAC registers, the omission of data on the type of abortion altogether in PAC registers, and reporting the total number but not the type of abortions treated in hospital data transmitted to state health authorities. The obscuration of suspected induced abortion in the record permits providers to circumvent police inquiry at the hospital. PAC has been implemented in approximately 50 countries worldwide. This study demonstrates the need for additional research on how medical professionals negotiate conflicting medical and legal obligations in the daily practice of treating abortion complications. [Copyright &y& Elsevier]

The article discusses the manipulation of information through the writing of documents and records by the royal officials of Ancien Régime France for the purposes of self-interest and self-promotion, as opposed to the use of information to promote the interests of the French king. While the author gives some attention to state propaganda, primary focus is given to manuscript descriptions of royal ceremonies, particularly those drawn up by King Louis XIV's Master of Ceremonies, Nicolas Sainctot, and his staff. The author notes how the writing of these records was bounded by customary law, which heightened the importance of the act of writing.

Purpose. A quality initiative to improve the management of heparin-induced thrombocytopenia (HIT) at an academic medical center, including the development of guidelines on the use of direct thrombin inhibitors (DTIs), is described. Summary. In keeping with the Joint Commission's National Patient Safety Goal (NPSG) for anticoagulant therapy (goal 03.05.01), a multidisciplinary working group conducted a needs assessment to identify areas for improvement in the center's HIT management practices, particularly the use of DTI therapy (an issue not specifically addressed by NPSG 03.05.01). The resulting action steps included (1) the implementation of a detailed protocol for the recognition and management of HIT, as well as guidelines on the use of the DTIs argatroban and lepirudin, (2) more efficient use and optimized documentation of initial and confirmatory tests in the electronic medical record (EMR), and (3) the education of pharmacists, nurses, and physicians on the use of the HIT protocol, with initial and ongoing case-based competency testing of pharmacy staff. Early postimplementation experience indicated that the protocol and associated activities have resulted in improved DTI prescribing and dosing, HIT documentation, and patient education practices while expanding pharmacists' involvement in ensuring optimal, cost-effective management of patients with HIT. Conclusion. In one institution, an HIT working group extended the scope of NPSG 03.05.01 to include the parenteral DTIs. The implementation of the HIT protocol has resulted in greater compliance with appropriate DTI dosing and improved EMR documentation of HIT. INSET: Identified Needs for Improving Management of Heparin-Induced.... [ABSTRACT FROM AUTHOR]

Wound assessment has developed into a specialized and complex area j of nursing practice. Care plans and interventions are based on the initial I assessment, which must therefore be accurate and clearly documented to support correct ongoing wound care and patient management. It is vital that the underlying and contributing patient factors to both wound development and healing, delayed healing or non-healing are considered throughout the process. Evaluation of interventions must be regular and consistent. This article will discuss the importance of holistic and collaborative assessment for the patient with a wound, exploring factors affecting healing and considerations to be made on initial and continous levels. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Communication practices of healthcare professionals have been strongly implicated in the cascade of events that unfold into poor outcomes for surgical patients. The purpose of this paper is to explore the role of documents and documentation in communication failure among healthcare professionals across the perioperative pathway. The perioperative pathway consists of 3 interconnecting, but geographically distinct domains: preoperative, intraoperative and postoperative. Design: A comprehensive search of the literature was undertaken to provide a focused analysis and appraisal of past research. Data sources: Electronic databases searched included the Cochrane Database of Systematic Reviews, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline and PsycINFO from 1990 to end February 2011. Additionally, references of retrieved articles were manually examined for papers not revealed via electronic searches. Review methods: Content analysis was used to draw out major themes and summarise the information. Results: Fifty-nine papers were selected based on their relevance to the topic. The results highlight that documentation such as surgeons’ operation notes, anaesthetists’ records and nurses’ perioperative notes, deficient in the areas of design, quality, accuracy and function, contributed to the development of communication failure among healthcare professionals across the perioperative pathway. The consequences of communication failure attributable to documentation ranged from inefficiency, delays and increased workload, through to serious adverse patient events such as wrong site surgery. Documents that involve the coordination of verbal communication of multidisciplinary surgical teams, such as preoperative checklists, also influenced communication and surgical patient outcomes. Conclusions: Effective communication among healthcare professionals is vital to the delivery of safe patient care. Multiple documents utilised across the perioperative pathway have a critical role in the communication of information essential to the immediate and ongoing care of surgical patients. Failure in the communicative function of documents and documentation impedes the transfer of information and contributes to the cascade of events that results in compromised patient safety and potentially adverse patient outcomes. [Copyright &y& Elsevier]

Scand J Caring Sci; 2011; 25; 220-226 To assess what was documented by Registered Nurses regarding diabetes care in a Swedish municipality's home nursing service; to what extent diabetes-related nursing actions were planned for, performed and evaluated according to the goals of metabolic control, treatment and prevention of complications. Cross-sectional study. Registered Nurses' documentation of patients with diabetes mellitus (n = 172). Number of recorded different nursing actions planned, performed and evaluated. The overall standard of records was insufficient. Evaluation of blood glucose levels and metabolic control was documented in 61% of the records; weight was documented in 4% of the records. Blood pressure was recorded in 10%. Ongoing foot ulcers were documented in 21%. Patient education or actions to prevent foot ulcers was not recorded. Tablet and insulin administration were well recorded. The nursing process was not followed. Updated medicine lists were missing in many files, this might have resulted in an underestimation of the number of included records. The Registered Nurses are responsible for a vulnerable patient group suffering from multi-organ disease unable to maintain their own diabetes self-care. Insufficient documentation may lead to impaired quality of care. We suggest that improved documentation routines include a structure of planning, performing and evaluation of metabolic control (blood glucose measurements, Hba1c, weight and nutrition status), complications (regular blood pressure measurements, protective foot care) and education of health care assistants in assisted diabetes self-care. [ABSTRACT FROM AUTHOR]

This literature review is part of a larger dissertation project that explores the lived experience of patients using long-term urinary catheters and nurses' attitudes towards urinary catheters. Systematic examination of the literature revealed six relevant primary research studies. These were critically appraised to assess their worth. Further studies were also reviewed, although these were often from neighbouring fields as relatively little research has been undertaken in this field. Findings suggest that there is a disparity between the care that nurses provide to patients with long-term catheters and the holistic care that patients need. Furthermore, nurses' decision-making skills are hampered by poor multidisciplinary documentation practices in the acute sector. It is concluded that nurses' attitudes towards urinary catheters do affect the care that patients receive. [ABSTRACT FROM AUTHOR]

An update summary should provide a fluent summarization of new information on a time-evolving topic, assuming that the reader has already reviewed older documents or summaries. In 2007 and 2008, an annual summarization evaluation included an update summarization task. Several participating systems produced update summaries indistinguishable from human-generated summaries when measured using ROUGE. However, no machine system performed near human-level performance in manual evaluations such as pyramid and overall responsiveness scoring. We present a metric called Nouveau-ROUGE that improves correlation with manual evaluation metrics and can be used to predict both the pyramid score and overall responsiveness for update summaries. Nouveau-ROUGE can serve as a less expensive surrogate for manual evaluations when comparing existing systems and when developing new ones. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to investigate if essential health and development data of all children in Sweden in the Child Health Service (CHS) and School Health Service (SHS) can be linked to the classification system International Classification of Functioning, Disability and Health — Children and Youth (ICF-CY). Method: Lists of essential health terms, compiled by professionals from CHS and SHS, expected to be used in the national standardised records form the basis for the analysis in this study. The essential health terms have been linked to the codes of ICF-CY by using linking rules and a verification procedure. Results: After exclusion of terms not directly describing children’s health, a majority of the health terms could be linked into the ICF-CY with a high proportion of terms in body functions and a lower proportion in activity/participation and environment respectively. Some health terms had broad description and were linked to several ICF-CY codes. The precision of the health terms was at a medium level of detail. Conclusion: ICF-CY can be useful as a tool for documenting child health. It provides not only a code useful for statistical purposes but also a language useful for the CHS and SHS in their work on individual as well as population levels. It was noted that the health terms used by services mainly focused on health related to body function. This indicates that more focus is needed on health data related to child’s functioning in everyday life situations. [ABSTRACT FROM PUBLISHER]

Background Assessment of weight and counselling on nutrition and physical activity is infrequently conducted during well child visits, despite recent expert recommendations. Objective We investigated whether automatic calculation of body mass index (BMI) in an electronic health record improved assessment of weight and counselling on nutrition and physical activity. Methods Retrospective review of well child visit records of children between two and 18 years of age (n=550) before and after implementation of an electronic health record system at an academic medical centre's paediatric clinic. Body mass index was automatically calculated and presented within the electronic health record. We measured clinicians' documentation of assessment of weight status, and assessment of and counselling for nutrition and physical activity risk factors. Results Documentation of assessment of BMI and weight status did not increase. There were no consistent increases in assessment for or counselling on specific nutrition and physical activity behaviours, except with respect to high calorie food intake. Although overall assessment of physical activity decreased, physical activity counselling significantly increased. Documentation of the presence of highrisk family history increased significantly; the provision of counselling for high-risk family history did not show any corresponding increase. Patients with higher BMI percentile scores were more completely assessed for weight status. Completeness of weight status assessment was associated with increased counselling for nutrition and physical activity. Conclusions Passive changes, such as automatic calculation of BMI, are insufficient to result in systematic improvements in assessment of weight and counselling for nutrition and physical activity. INSET: Clinical relevance of body mass index (BMI) in children. [ABSTRACT FROM AUTHOR]

Central to the assessment process in case management is how older people’s needs are constructed through documentation and case files. This article examines how older people’s needs are categorized in written documentation. Sixteen case files from three social work districts in Sweden were studied using discourse analysis. The results identified two general types of case files; the fact-oriented (using objective language) and event-oriented case file (using more personal language) — which depicted the older individuals quite differently. All case files employed several need categories; though social needs were important in describing living conditions, it was medical and physical needs that impinged on home care decisions. This raises questions about how case documentation depicts older people through society’s eyes and about the discourses prevailing in gerontological social work. [ABSTRACT FROM AUTHOR]

Scand J Caring Sci; 2010; 24; 764-771 Pain is one of the most frequent symptoms for which people seek emergency care. Studies show that pain management in emergency clinics is insufficient. No previous studies regarding pain documentation at emergency clinics in the Nordic countries have been undertaken. The main purpose was to investigate the extent to which pain assessment, pain treatment and pain relief were documented in patient records. Patient records were reviewed using a study-specific protocol. Emergency unit at a Swedish university hospital. A total of 698 patient records randomly selected were reviewed using a study-specific protocol. According to Swedish law and the university hospital's quality and safety guidelines, there should be a note in each patient record regarding whether or not the patient was in pain on arrival. The guideline stresses the importance of using patient self-assessment by a visual analogue scale (VAS). In 361/698 (52%) records, there was a note by a doctor or a nurse as to whether or not the patient had been experiencing pain on arrival. In 319 of these 361 records (88%), a full pain assessment had been documented. In 15/319 (5%) cases, the pain assessment included patient VAS assessment. In 54/319 (17%) patient records, a note regarding pain treatment was found. Significantly more notes regarding pain treatment were found in the records with an initial documented pain assessment, when compared with the records without any such assessment (p < 0.01). In the 54 records with notes regarding pain treatment, 10 (19%) included documentation regarding the effect of the treatment. The results show an alarming lack of documentation regarding pain assessments, pain treatments and follow-ups. This is in marked contrast to Swedish law, which clearly stipulates the responsibility of health care staff to document information relevant to providing safe care. Prompt action to improve pain documentation is warranted. [ABSTRACT FROM AUTHOR]

Evidence suggests that nurse documentation is often inconsistent and lacks a coherent and standardized approach. This article reports on research into the use of nurse documentation on a stoma care ward in a large London hospital, and explores the factors that may affect the process of record keeping by nursing staff. This study uses stoma care as a case study to explore the role of documentation on the ward, focusing on how this can be improved. It is based on quantitative and qualitative methods. The medical notes of 56 patients were analysed and in addition, focus groups with a number of nurses were undertaken. Quantitative findings indicate that although 80% of patients had a chart filed in their medical notes, only a small portion of the form was completed by nursing staff. Focus group findings indicate that this is because forms lacked standardization and because the language used was often ambiguous. Staff also felt that such documentation was not viewed by other nurses and so, was not effective in improving patient care. As a result of this study, significant improvements have been made to documentation used on the stoma care ward. This is an important exploration of record keeping within nursing in the context of the Nursing and Midwifery Council's emphasis on the importance of documentation in achieving effective patient outcomes. [ABSTRACT FROM AUTHOR]

johnson m., jefferies d. & langdon r. (2010) Journal of Nursing Management The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool Background The Nursing and Midwifery Content Audit Tool (NMCAT) was developed to monitor the quality of nursing documentation. Methods A health care record audit was conducted on 200 records. Using a time-sampling approach, recent nursing documentation was examined. Inter-rater reliability was determined at 85% agreement between two raters. Results The NMCAT criteria relating to the recording of the patients' health status, use of objective information and logical presentation were met to a high level. The patients' response to treatment or nursing interventions including medications requires attention. The recording of events immediately after they have occurred was limited. The structure of the sentences and language used, restricted the readability of the documentation. The widespread use of local abbreviations, often connected together to form the text, was problematic. Conclusions The present study provides new audit solutions based on time-sampling approaches and focused evidence-based criteria. The use of language support software and writing coaches to improve the presentation of nursing documentation is recommended. Implications for Nursing Management The NMCAT is a time-efficient tool available to managers for monitoring the quality of nursing documentation, either at a unit level or across health facilities to demonstrate compliance with quality standards. [ABSTRACT FROM AUTHOR]

The article presents the author's views on the usability of electronic medical records (EMRs) in the U.S. He highlights the arguments of Shahid Shah, chief executive officer (CEO) of Netspective Communications, that physicians have moved away from EMRs due to their negative impact on productivity. However, according to the author, EMRs will achieve their potential to improve and efficiency in health information documentation. He also argues that regulatory intervention are not the cause of EMRs usability problem but believes that the combination of user-friendly EMRs and customers is the most efficient way of improving EMR usability.

Abstract: Recording information of the strata removed during the cleaning process requires not only gathering information concerning the physical characteristics (description) of each strata and its composition, but also, gathering information concerning a stratum''s relationships. In general, photographs, sections and maps are used in order to record the different layers (overpaint, filler, varnish...). These recording systems are very important but they are usually insufficient when the aim is to record complex stratigraphic structures. The objective of this research has been to develop a recording system to record non-original deposits removed during the cleaning of paintings. In order to do so, a number of tools have been borrowed from stratigraphic archaeology, such as a recording sheet for each stratum eliminated and a stratigraphic diagram. This allows a standardized documentation to be obtained, which can be studied by any given researcher in order to understand how the non-original layers were arranged before cleaning and exactly how the cleaning was carried out. [Copyright &y& Elsevier]

It has been suggested that one of the purposes of archival description is to establish grounds for presuming the authenticity of the records being described. The article examines the implications of this statement by examining the relationship between and among authenticity, archival description, and archival accountability, assessing how this relationship is made manifest in a contemporary archival description standard—the General International Standard for Archival Description—and considering the relationship between description and documentation. [ABSTRACT FROM AUTHOR]

The article discusses how the notion of documentality affects the process of construction of social reality in Europe. It states that documentality is a necessary process of attestation for the existence of a society. It cites that the European decline, has in fact happened on the plane of documents, as the abasement concerning to inscriptions. It also cites the rise of the dollar as international currency and the peace conference of Versailles in 1919, as an example of documentation.

Résumé: Le droit applicable au médicament à usage humain est aujourd’hui quasiment régi en totalité par le droit communautaire, laissant très peu de marge d’appréciation aux États membres. Ce constat s’est trouvé renforcé dans le cadre de l’application du principe de libre circulation des biens, qui vient limiter de façon stricte le refus, de la part d’un État membre, de reconnaître une autorisation de mise sur le marché (AMM) délivrée par un autre État membre. [Copyright &y& Elsevier]

Résumé: En janvier 2006, l’institut universitaire de médecine légale a ouvert l’unité de médecine des violences qui offre une consultation médicolégale spécialisée dans la prise en charge des adultes victimes de violence. La consultation est assurée par des infirmières dont la formation et la supervision sont conduites par des médecins légistes. Une écoute, un examen clinique en vue d’établir la documentation médicolégale et une orientation sont proposés aux patients. [Copyright &y& Elsevier]

Buxton and Myers (1986) compared a specialized document navigation device and a scrollbar. Their device tracked finger movements along two touch-sensitive areas: one for absolute movement and one for relative movement. They found that their system was faster when navigating a 5-page document. We identified finger-tracking issues with the Buxton and Myers device for larger documents (100 pages) and developed an alternative device employing a range sensor and rotary encoder to track finger movement. We ran a new experiment comparing the traditional scrollbar, the Buxton and Myers design, and our new design. Both the Buxton and Myers design and our new design were poorly received by users compared to the scrollbar. Our results indicate that in a large document, factors beyond finger tracking accuracy influence the performance of a device providing absolute movement. From these results, we identify possible improvements necessary to implement effective and practical absolute navigation devices. [ABSTRACT FROM AUTHOR]

The article looks at current legal developments in the United Nations (UN) Food and Agriculture Organization (FAO). In 2008, significant movement has happened in the development of a FAO Global Record of Vessels. From February 25-28, 2008, the organization initiated an expert consultation regarding the development of a global record of fishing vessels, refrigerated vessels and fishing support vessels. The main objective of the consultation was to understand the feasibility of a FAO Global Record (GR) and how the GR could be developed.

This pilot study proposes a set of analytical steps for comparing schools that participate in the National Science Foundation's Math and Science Partnership (MSP) Program and their nonparticipating peers in the same state. This pilot is part of a larger effort to evaluate the MSP Program's role in student achievement, with two companion analyses. Although our pilot study uses a comparative approach, the study by Dimitrov in this issue follows a within-group design. The third analysis by Yin and his associates in this issue covers the varied designs used by the MSPs themselves in their own evaluations. In this pilot, we focus on a sample of participating schools in one MSP in one state. The nonparticipating schools were carefully matched with the program participating schools on eight demographic variables to form a comparison group. This article offers detailed documentation on how we operationalize two matching methods for comparative purpose. We conclude that carefully executed matching methods are promising for large scale comparative analysis on the effects of the MSP Program across different states. [ABSTRACT FROM AUTHOR]

This paper shows the procedures that the German Embassy in Madrid used since 1933 to reach the German audiences who were living in Spain. It is focused on the distribution and willingness to promote propaganda documentaries; how the German authorities did it and which outcomes they got. Unpublished documentation from the German and Spanish archives are utilized. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to discuss the results of a customer knowledge study commissioned by the Parliamentary Documentation Centre (PDC) of the European Parliament in order to elicit a better understanding of the views and needs of its actual and potential client base. Design/methodology/approach - The study consisted of in-depth, face-to-face interviews with 72 clients and 11 staff (83 individuals) in Brussels in February 2004. The paper explores the significance of information in the parliamentary context and summarises the activities which respondents described as being information-dependent. The paper also highlights the evolutionary nature of information need during the course of the legislative process. Findings - The information-seeking behaviour and skills of the PDC clients are discussed, as are the criteria by which they assess information quality. The study revealed that users were frequently uncritical and pragmatic in use of the most readily available information, sacrificing quality in favour of ease of access. Originality/value - This paper presents results from a uniquely complex information environment - the European Union. Users tended to be complacent about their information-seeking skills and reluctant to engage in skills enhancement activities. [ABSTRACT FROM AUTHOR]

This article provides a preliminary history of the first 35 years of the Canadian Association for Information Science/ L'Association canadienne des science de l'information (CAIS-ACSI), which was founded in 1971. The association's records are incomplete and dispersed, and gaps remain to be filled, but those we have illustrate the energy with which the new discipline and practice of information science was embraced by enthusiasts, practitioners, and scholar. The association's formation and early activities, its changing structure, membership, advocacy work, publications, conferences, and various electronic expreiments are covered here. A thorough history of information science in Canada remains to be written [ABSTRACT FROM AUTHOR]

It is studied the process of the first handbook on Spanish palaeography and its protagonists. All the details of this venture are deeply analysed, starting from filed documentation, as well as from consultation of preserved handbooks. Several aspects are dealt with, such as project management, budget, paper, types of print, print run, as well as distribution and sale of copies in two different typographic moments. [ABSTRACT FROM AUTHOR]

These documents, dated in 1899, give information relative to the establishment of morgue of Santiago, predecessor of the present Legal Medical Service, and on some of the procedures used at the time with corpses found in the streets. [ABSTRACT FROM AUTHOR]

In the Netherlands, police records are routinely drawn up in the course of the interrogation. As a result, recording practices are closely interwoven with interrogation activities. The interrogation is organized to accommodate the recording, and the recording informs the interrogation. The record is not merely a document in which what is said is written down, it actively informs and directs the interrogation: The record-thus-far is used by the interrogator as a resource to carry on the interrogation. Consequently, what gets written down in the record and is eventually used as evidence in a criminal law case is not just a reflection of what the interrogator has asked and the suspect has answered but also a result of the interrogator's solutions to problems of coordinating the talk and the typing. Thus, police records can only be understood fully by taking into account the practices of their construction. [ABSTRACT FROM AUTHOR]

The article discusses the context of preserving cultural records. According to the author, the most significant change in the cultural record is not scholarship, government records, and music and visual art but audio and video recordings. Cultural record is composed of the scholarship that gathers, sorts and analyzes what people know or think they know. He asserts that culture has become a weapon of mass distinctions of the social sort, and in the U.S. the reaction of some people to the word is a product of egalitarianism and populism.

Evidence is an important concept for archivists at the same time that it is a hard one to pin down in so many words. Our understanding tends to suffer from a general assumption that the notion is somehow self-evident (that we know what we mean without having to spell it out), as well as from a narrow conceptualization that inextricably links the notion with legal rules, accountability, and corporate memory. With the renewed interest in and debate surrounding the subject in recent years (especially since the advent of electronic records), it is important for archivists to clarify and elaborate on our ideas of evidence and to work towards formulating our own concept with a meaning expressed and explored in archival terms. This paper seeks to do so by tracing an archival concept of evidence as a relation between record and event (drawn from legal conceptions of evidence as a relation between two facts), by considering the concept's various assertions about the nature of records and certain archival processes, and by imagining the possible applications and implications of the concept as a term of archival thought and practice. In the end, this paper does not seek to offer a singular archival meaning of evidence so much as to begin a line of inquiry that hopefully opens up our understanding of evidence and leads to different discussions of some of the key ideas informing and shaping our individual and collective practice. [ABSTRACT FROM AUTHOR]

The archive is the place for the storage of documents and records. With the emergence of the modern state, it became the storehouse for the material from which national memories were constructed. Archives also housed the proliferation of files and case histories as populations were subjected to disciplinary power and surveillance. Behind all scholarly research stands the archive. The ultimate plausibility of a piece of research depends on the grounds, the sources, from which the account is extracted and compiled. An expanding and unstable globalizing archive presents particular problems for classifying and legitimating knowledge. Increasingly the boundaries between the archive and everyday life become blurred through digital recording and storage technologies. Not only does the volume of recordable archive material increase dramatically (e.g. the Internet), but the volume of material seen worthy of archiving increases too, as the criteria of what can, or should be, archived expands. Life increasingly becomes lived in the shadow of the archive. [ABSTRACT FROM AUTHOR]

The article features the documents of the Library of Michigan (LM) in Michigan. It offers a chronological account on the collection and preservation strategies and the start of the digital state documentation. It discusses the effects of the introduction of the Michigan E-documents, a digital format of government information to the State Depository Program and depository libraries. It explains the efforts of LM to find a single processes and system that will track and accommodate digital acquisition and preservation. Lastly, it reports on the legislations which contradict the aims of LM.

The article discusses the advocacy of Witness. It is a human rights organization working in partnership with other non government organizations that is helping in the incorporation video in advocacy campaigns in various issues around the world. The Witness Media Archive is a product of the partnership. It aims to serve the archival needs of the partners in the long term and provides on going production and distribution support. It also aims to preserve the media as documentation's for human rights records and provides access to a broader community of advocates, journalist and film makers.

Social workers' understanding of the relevance of documentation has evolved over time. During the profession's earliest years, social workers viewed documentation primarily as a mechanism to facilitate theory building, research, and teaching. This was followed by social workers' development of detailed and sophisticated documentation standards for clinical and other direct practice settings. Most recently, social workers have begun to appreciate the relevance of documentation for risk-management purposes, particularly as a tool to protect clients and to protect practitioners in the event of an ethics complaint or lawsuit. This article updates the profession's literature on documentation by summarizing current ethical and legal standards. Implications for social work practice, supervision, management, and administration are addressed. [ABSTRACT FROM AUTHOR]