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This article hypothesizes that one of the reasons for Chinese EFL learners' rigid use of nominalization and insufficient use of hedging in academic writing can be attributed to the unclear understanding of the relationship between these two expressions. The aim of the research is to first prove and then explain the possible co-occurrence of nominalization and hedging in scientific papers, with the intention of deepening Chinese EFL learners' understanding of the reasons for their possible co-occurrence. After a corpus-assisted statistical analysis of sixty abstracts selected from leading scientific journals written by native English speakers, it's been found that there is indeed a tendency for nominalization and hedge to co-occur both at the textual-level and clause-level. Besides, a tentative analysis is conducted to explain the pattern of their co-occurrence. It has been observed that the number of nominalized expressions in clauses is inversely correlated with the probability degree of hedging, and the position of nominalization in the clause (theme or rheme) influences the generalization level of hedging. The research results could shed light on the pedagogic approach in improving Chinese EFL learners' academic writing by making evident that the elusive Grammatical Metaphor competence could be enhanced by deepening the understanding of the inter-relationship between seemingly different in-congruent expressions like nominalization and hedges.

This essay uses the reprocessing of the "Luis Alberto Sánchez papers," the collection of a prominent Peruvian politician and author housed at Penn State University, to argue that ethical and reparative processing needs should be prioritized within an archives' overall extensible processing program. The author explores the tension between two differing threads within the archival literature of: (1) using minimal or extensible processing practices to efficiently process backlogs; and (2) of acknowledging the power of archivists in shaping the historical record and their ethical responsibilities towards communities represented within their collections. This essay argues that archivists should prioritize collections where archival practices have perpetuated in obfuscating or marginalizing the records of traditionally underrepresented communities. It also argues that prioritizing this work capitalizes on the inherent flexibility within an extensible processing framework.

Introduction: The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated., Purpose: To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans., Methods: A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study., Results: There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes., Conclusions: The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Introduction: There have been several concerns about the quality of documentation in electronic health records (EHRs) when compared to paper charts. This study compares the accuracy of physical examination findings documentation between the two in initial progress notes., Methodology: Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak, between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training., Results: The rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians., Conclusions: During the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. Residents had a lower rate of inaccuracies and omissions compared to attending physicians. Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The present study is an attempt to discover whether Iraqi EFL College Students are aware of research plagiarism or they are not. To manage this study the researchers set three questions, aims, and hypotheses. Thus they prepare a questionnaire (of five domains and 25 items) to be conducted on 116 male and female fourth year students from department of English/College of Education/University of Kerbala. The results show that they are unaware of plagiarism because they are not acquainted with the right way of avoiding plagiarism. A t-test has been use to show whether there are differences between males and females, and the result shows no statistical difference. Moreover, a set of conclusions such as students are not acquainted with the right way of documentation because the textbook is relatively old, they don't have enough practical training in writing research paper. Finally, recommendations have been presented such as: The instructors (whether professors or teachers) should focus on the ethical considerations in writing papers, the textbook should be updated occasionally to match the need of the new academic publishing requirements.

Background: The Syria crisis has forced more than 4 million people to leave their homeland. As a result, in 2016, an overwhelming number of refugees reached Germany. In response to this, it was of utmost importance to set up refugee camps and to provide humanitarian aid, but a health surveillance system was also implemented in order to obtain rapid information about emerging diseases., Objective: The present study describes the effects of using digital paper and pen (DPP) technology on the speed, sequence, and behavior of epidemiological documentation in a refugee camp., Methods: DPP technology was used to examine documentation speed, sequence, and behavior. The data log of the digital pens used to fill in the documentation was analyzed, and each pen stroke in a field was recorded using a timestamp. Documentation time was the difference between first and last stroke on the paper, which includes clinical examination and translation., Results: For three months, 495 data sets were recorded. After corrections had been made, 421 data sets were considered valid and subjected to further analysis. The median documentation time was 41:41 min (interquartile range 29:54 min; mean 45:02 min; SD 22:28 min). The documentation of vital signs ended up having the strongest effect on the overall time of documentation. Furthermore, filling in the free-text field clinical findings or therapy or measures required the most time (mean 16:49 min; SD 20:32 min). Analysis of the documentation sequence revealed that the final step of coding the diagnosis was a time-consuming step that took place once the form had been completed., Conclusions: We concluded that medical documentation using DPP technology leads to both an increase in documentation speed and data quality through the compliance of the data recorders who regard the tool to be convenient in everyday routine. Further analysis of more data sets will allow optimization of the documentation form used. Thus, DPP technology is an effective tool for the medical documentation process in refugee camps., (©Kai Kehe, Roland Girgensohn, Walter Swoboda, Dan Bieler, Axel Franke, Matthias Helm, Martin Kulla, Kerstin Luepke, Thomas Morwinsky, Markus Blätzinger, Katalyn Rossmann. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 19.08.2019.)

Background: Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project ("National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany") has used the "German Emergency Department Medical Record" (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry., Methods: Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time., Results: All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001)., Conclusions: We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

Purpose: To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment., Methods: This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated., Results: Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms)., Conclusions: Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Most preventable adverse drug events and medication errors occur during medication ordering. Medication order entry and clinical decision support are available on paper or as computerized systems. In this post-hoc analysis we investigated frequency and clinical impact of blood glucose (BG) documentation- and user-related calculation errors as well as workflow deviations in diabetes management. We aimed to compare a paper-based protocol to a computerized medication management system combined with clinical workflow and decision support., Methods: Seventy-nine hospitalized patients with type 2 diabetes mellitus were treated with an algorithm driven basal-bolus insulin regimen. BG measurements, which were the basis for insulin dose calculations, were manually entered either into the paper-based workflow protocol (PaperG: 37 patients) or into GlucoTab(®)-a mobile tablet PC based system (CompG: 42 patients). We used BG values from the laboratory information system as a reference. A workflow simulator was used to determine user calculation errors as well as workflow deviations and to estimate the effect of errors on insulin doses. The clinical impact of insulin dosing errors and workflow deviations on hypo- and hyperglycemia was investigated., Results: The BG documentation error rate was similar for PaperG (4.9%) and CompG group (4.0%). In PaperG group, 11.1% of manual insulin dose calculations were erroneous and the odds ratio (OR) of a hypoglycemic event following an insulin dosing error was 3.1 (95% CI: 1.4-6.8). The number of BG values influenced by insulin dosing errors was eightfold higher than in the CompG group. In the CompG group, workflow deviations occurred in 5.0% of the tasks which led to an increased likelihood of hyperglycemia, OR 2.2 (95% CI: 1.1-4.6)., Discussion: Manual insulin dose calculations were the major source of error and had a particularly strong influence on hypoglycemia. By using GlucoTab(®), user calculation errors were entirely excluded. The immediate availability and automated handling of BG values from medical devices directly at the point of care has a high potential to reduce errors. Computerized systems facilitate the safe use of more complex insulin dosing algorithms without compromising usability. In CompG group, missed or delayed tasks had a significant effect on hyperglycemia, while in PaperG group insufficient precision of documentation times limited analysis. The use of old BG measurements was clinically less relevant., Conclusion: Insulin dosing errors and workflow deviations led to measurable changes in clinical outcome. Diabetes management systems including decision support should address nurses as well as physicians in a computerized way. Our analysis shows that such systems reduce the frequency of errors and therefore decrease the probability of hypo- and hyperglycemia., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Circulated documents, like mission statements, demarcate normative boundaries related to student and instructor identities, behaviors, and experiences. In attempting to create inclusive documentation, universities frequently use standardizing language. While promoting standardization, however, such documents may prove exclusive by disregarding a range of student and instructor identities and abilities. Grounded in insights from disability studies and technical and professional communication theory, this study models the use of corpus linguistic analysis for analyzing mission statements, thereby providing interdisciplinary methods for writing programs to evaluate the documents they create and circulate. The findings show that by attempting to universalize experience, composition programs may contribute to normalizing structures that circulate ableism. These findings help programs recognize the discursive impact that mission statements may have by illustrating how ableism may move across even seemingly neutral spaces. In turn, the article calls for composition studies to consider critical documentation practices that prioritize disability and offers data-driven guidelines for revising mission statements.

Objective: Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR., Methods: We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center., Results: We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency; (2) knowledge/skill/ease of use; (3) memory; (4) sensorimotor preferences; (5) awareness; (6) task specificity; (7) task complexity; (8) data organization; (9) longitudinal data processes; (10) trust; and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR., Conclusions: In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation.

Objective: Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR., Materials and Methods: Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR., Results: Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after "go-live". These increases abated at differing rates predicted by participants' computer attitudes scores (p = 0.01)., Conclusions: There is substantially increased cognitive workload for nurses during the early phases (1-5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to "meaningful use" EHRs. "One-size-fits-all" training strategies may not be suitable and longer periods of technical support may be necessary for some workers., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: The United Nations' Sustainable Development Goal #3.8 targets 'access to quality essential healthcare services'. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones., Intervention: The Guidelines Adherence in Slums Project targeted ten private sector primary healthcare clinics serving informal settlements in Nairobi, Kenya. Each clinic was provided with rubber stamp templates to support documentation and management of commonly encountered outpatient conditions. Participatory design methods were used to customize templates to the workflows and infrastructure of each clinic. Rubber stamps were used to print templates into paper charts, providing clinicians with checklists for use during consultations. Templates used bubble format data entry, which could be digitized from images taken on mobile phones. Besides rubber stamp templates, the intervention included booklets of guideline compilations, one Android phone for digitizing images of templates, and one data feedback/continuing medical education session per clinic each month. In this paper we focus on the effect of the intervention on documentation of three non-communicable diseases in one clinic., Methods: Seventy charts of patients enrolled in the chronic disease program (hypertension/diabetes, n=867; chronic respiratory diseases, n=223) at one of the ten intervention clinics were sampled. Documentation of each individual patient encounter in the pre-intervention (January-March 2016) and post-intervention period (May-July) was scored for information in four dimensions - general data, patient assessment, testing, and management. Control criteria included information with no counterparts in templates (e.g. notes on presenting complaints, vital signs). Documentation scores for each patient were compared between both pre- and post-intervention periods and between encounters documented with and without templates (post-intervention only)., Results: The total number of patient encounters in the pre-intervention (282) and post-intervention periods (264) did not differ. Mean documentation scores increased significantly in the post-intervention period on average by 21%, 24% and 17% for hypertension, diabetes and chronic respiratory diseases, respectively. Differences were greater (47%, 43% and 27%, respectively) when documentation with and without templates was compared. Changes between pre- vs.post-intervention, and with vs.without template, varied between individual dimensions of documentation. Overall, documentation improved more for general data and patient assessment than in testing or management., Conclusion: The use of templates improves paper-based documentation of patient care, a first step towards improving the quality of care. Rubber stamps provide a simple and low-cost method to print templates on demand. In combination with ubiquitously available mobile phones, information entered on paper can be easily and rapidly digitized. This 'frugal innovation' in m-Health can empower small, private sector facilities, where large numbers of urban patients seek healthcare, to generate digital data on routine outpatient care. These data can form the basis for evidence-based quality improvement efforts at large scale, and help deliver on the SDG promise of quality essential healthcare services for all., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality., Methods: A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources., Results: A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease 'inappropriate referrals' by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness., Conclusion: Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.

This paper is based on a study that examined authorship and collaborative research among scholars in Open and Distance Learning (ODL) institutions with a focus on prospects for Africa. The study involved intensive documentary desk review of conference book of abstracts and conference proceedings to examine authorship and collaborative research. The study reviewed a total of 10 conference books of abstracts and proceedings organized or hosted by universities including ODL institutions in Africa. Descriptive statistics were used to summarise some thematic areas of interest. It is revealed in this paper that authorship in terms of co-authorship is high in some conferences but low in others in relation to collaborative research. Furthermore, authorship between two scholars was higher compared to three or more authors in collaborative research. This implies that co-authorship is trending in relation to collaborative research thus raising collaboration prospects for Africa. It is therefore recommended that ODL scholars should be encouraged to do more co-author publications from collaborative research in order to promote teamwork and comparative studies in knowledge production for socio-economic development relevant for Africa and beyond.

This article presents the results of the analysis of the first two Charters of Saint Petersburg Mining University. A short period of educational activity of the first t in Russia is represented: from the date of the decree founding the Mining School in 1773 and the first Charter approved by Catherine II to the beginning of the XIX century, namely, 1804, the year of the second Charter. These documents are considered in their cultural and historical context, and the continuity in the implementation of education and training of mining engineers is revealed. Authors compare the Charter of the Mining School (1774) with the Charter of the Land Gentry Cadet Corps (1766), as well as the Charter of the Mining Cadet Corps (1804) with the Charter of Moscow University (1804). The Charters of the last third of the XVIII -- early XIX centuries contain objective information about the formation of the higher education system in Russia. The origins of two branches of higher education in Russia, classical University and higher technical educational institution, are indicated. Within the framework of the examined texts, a range of topics and issues discussed in the Charter as in organizational and legal document is highlighted. Universal character of the Charter as a document of its time, including a description of various aspects of activities of the educational institution, is noted. Analysis of the texts showed that Charters of the Mining School and the Mining Cadet Corps determined the life order of a closed educational institution. At the heart of its work was the task of educating a new person for a state service. All this allows us to consider the Charter as a historical and cultural document of a certain period.

The present study is intended to critically examine metadiscourse markers in 24 master thesis abstracts. Twelve of them are written by non-native Iraqi female students and the rest by native American female students. To do so, the researchers have set two aims: examining the types and subtypes of metadiscourse markers in terms of nativity and major and comparing the usages of metadiscourse markers' types and subtypes in terms of nativity. To achieve the present aims, Hyland's model (2005) is adopted. It aids in classifying the types and subtypes of metadiscourse markers in both data. The findings show that the Iraqi and American researchers use the interactive resources more than the interactional ones but the American researchers are capable of engaging their readers since their use of the interactional markers is higher than their counterparts. The field has no effect on the use of metadiscourse markers. There is diversity in the usage of the interactive resources in Iraqi data. Accordingly, the researchers recommend metadiscourse markers to be added to M.A courses as part of abstract writing exercise and the instructors of fourth-year college students to include metadiscourse markers in the writing of their research papers for coherence and clarity.

Objective: To investigate time differences in recording observations and an early warning score using traditional paper charts and a novel e-Obs system in clinical practice., Methods: Researchers observed the process of recording observations and early warning scores across 3 wards in 2 university teaching hospitals immediately before and after introduction of the e-Obs system. The process of recording observations included both measurement and documentation of vital signs. Interruptions were timed and subtracted from the measured process duration. Multilevel modeling was used to compensate for potential confounding factors., Results: In all, 577 nurse events were observed (281 paper, 296 e-Obs). The geometric mean time to take a complete set of vital signs was 215 s (95% confidence interval [CI], 177 s-262 s) on paper, and 150 s (95% CI, 130 s-172 s) electronically. The treatment effect ratio was 0.70 (95% CI, 0.57-0.85, P  < .001). The treatment effect ratio in ward 1 was 0.37 (95% CI, 0.26-0.53), in ward 2 was 0.98 (95% CI, 0.70-1.38), and in ward 3 was 0.93 (95% CI, 0.66-1.33)., Discussion: Introduction of an e-Obs system was associated with a statistically significant reduction in overall time to measure and document vital signs electronically compared to paper documentation. The reductions in time varied among wards and were of clinical significance on only 1 of 3 wards studied., Conclusion: Our results suggest that introduction of an e-Obs system could lower nursing workload as well as increase documentation quality., (© The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Aim: Known adverse drug reactions (ADRs) can have profound effects on disease states, as well as prescribing practice. Therefore, the correct and complete documentation of each individual patient's ADR history, upon hospital admission, is important in optimising that individual patient's pharmacotherapy. This study investigated the documentation of ADRs at a tertiary New Zealand hospital, on both paper-based medication charts and electronic medication charts to quantify both the number of ADRs patients self-report, as well as the differences between recording of that information in electronic and paper-based charting systems., Method: Following ethical approval, inpatient medication charts on the general medical ward (electronic prescribing), or the general surgical ward (paper-based medication charts) were viewed for documented ADRs-as reported by each patient on admission. Consecutive patient charts (and electronic clinical management system) were viewed until 50 patients from each ward, each with at least one documented ADR, (in any of the information sources) were obtained. Patient demographic information, ADR history and discrepancies between information sources were determined., Results: In both wards 114 patients were reviewed in order to find 50 patients with documented ADRs. In the medical ward (electronic) 44 (90%) patients had discrepancies in ADR information between different information sources and in the surgical ward (paper) this occurred in 49 (98%) patients., Conclusion: A large number of patients self-report ADRs. Full documentation of patient reported ADRs is required to adequately inform future prescribing decisions. Discrepancies between ADR information recorded in different information systems exist, but information sharing between electronic and non-electronic sources could be prioritised in order to allow full and complete information to be collected, stored and utilised; and reduce the current inadequacies.

Purpose: To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records., Methods: Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level., Results: Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p<0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p<0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p<0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p<0.01), suggesting more items designed in a form, more information would be captured., Conclusion: Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

While the conference abstract is not the only important factor in determining acceptance or rejection to present at a conference, it is probably the most significant one. No matter how timely and relevant your intended presentation might be, if your conference abstract does not show that you have a proposal worth presenting, you risk not having your proposal accepted. In the article, the author does the following: (1) explain what the conference abstract is; (2) go over challenges of writing a conference abstract; (3) offer suggestions for preparing to write; (4) outline common requirements; a (5) provide an overview and samples of the common parts of the conference abstract; (6) offer a checklist for reviewing the conference abstract; and (6) explain the promissory abstract. Her hope is that readers will finish the article with an understanding of conference abstracts and a clearer sense of how to write them effectively.

Background : The current UK standard for major trauma patients is to record notes in a paper trauma booklet. Through an innovative collaboration between a major trauma centre and a digital transformation industry partner, a TraumaApp was developed. Electronic notes have been shown to have fewer errors, granular data collection and enable time stamped contemporaneous record keeping. Implementation of digital clinical records presents a challenge within the context of trauma multidisciplinary trauma resuscitation. Data can be easily accessible and shared for quality improvement, audit and research purposes. This study compared paper and electronic notes for completeness and for acceptability data following the implementation of the TraumaApp. Methods: Trauma team members who performed scribe function attended training for the newly launched TraumaApp. Two staff members acted as scribe, using either the paper trauma booklet or TraumaApp, and attended major trauma calls. A framework for comparison of paper and electronic notes was created and used for a retrospective review of major trauma patients' notes. Statistical analysis was performed using a two-tailed t-test. Staff using the TraumaApp completed a System Usability Score questionnaire. Results: There was a total of 37 data points for collection per case. The mean numbers collected were paper notes 24.1 of 37 (65.1%) and electronic notes, 25.7 of 37 (69.5%). There was no statistical significance between the completeness of paper and electronic notes. The mean System Usability Score was 68.4. Discussion: Recording accurate patient information during a major trauma call can be challenging and the role of the scribe to accurately record events is critical for immediate and future care. There was no statistically significant difference in completeness of paper and electronic notes, however the mean System Usability Score was 68.4, which is greater than the internationally validated standard of acceptable usability. Conclusion: It is feasible to introduce digital data collection tools enabling accurate record keeping during trauma resuscitation and improve information sharing between clinicians. [ABSTRACT FROM AUTHOR]

PurposeTo assess time requirements for patient encounters and estimate after-hours demands of paper-based clinical workflows in ophthalmology.DesignTime-and-motion study with a structured survey.MethodsThis study was conducted in a single academic ophthalmology department. A convenience sample consisted of 7 attending ophthalmologists from 6 subspecialties observed during 414 patient encounters for the time-motion analysis and 12 attending ophthalmologists for the survey. Outcome measurements consisted of total time spent by attending ophthalmologists per patient and time spent on documentation, examination, and talking with patients. The survey assessed time requirements of documentation-related activities performed outside of scheduled clinic hours.ResultsAmong the 7 attending ophthalmologists observed (6 men and 1 woman), mean ± SD age 43.9 ± 7.1 years, during encounters with 414 patients (57.8 ± 24.6 years of age), total time spent per patient was 8.1 ± 4.8 minutes, with 2.8 ± 1.4 minutes (38%) for documentation, 1.2 ± 0.9 minutes (17%) for examination, and 3.3 ± 3.1 minutes (37%) for talking with patients. New patient evaluations required significantly more time than routine follow-up visits and postoperative visits. Higher clinical volumes were associated with less time per patient. Survey results indicated that paper-based documentation was associated with minimal after-hours work on weeknights and weekends.ConclusionsPaper-based documentation takes up a substantial portion of the total time spent for patient care in outpatient ophthalmology clinics but is associated with minimal after-hours work. Understanding paper-based clinical workflows may help inform targeted strategies for improving electronic health record use in ophthalmology.

Introduction: Paper-based documents are subject to problems related to storage, loss, distribution and editing. Many organizations have introduced ICT-based processes to reduce the use of paper as primary documentation. Nevertheless, paper documents are still being used in healthcare., Purpose: To better understand this situation, we have studied the use of paper-based patient lists in two wards in a Norwegian hospital that has 'gone digital'. We seek to answer the question: "Why is it that paper-based patient lists are maintained in the ward of a hospital going digital?", Methods: Participant observations and semi-structured interviews with stakeholders., Results: Patient lists allow nurses to immediately record, retrieve, and share relevant patient information at the point of care in a way that is not immediately available through the EPR system. Paper-based tools continue to serve purposes beyond and outside what is currently supported by current electronic information systems., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR., Methods: We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records., Results: Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording., Conclusion: This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records.

Research on note taking in pedagogical settings has received considerable attention. However, the awkwardness of integrating information across different media formats may present physical and cognitive barriers that prevent students from effectively organizing annotations from both printed and digital content while studying paper textbooks. The purpose of this paper is to develop a cross-media annotation system that incorporates a paper textbook with a computer as an integrated whole to facilitate the question-driven organization of annotations. While taking notes, students can digitally extract printed text and organize the copied passages based on guiding questions, all by using digital pens. Students can also link Internet-based learning resources to printed content to supplement their print-based studies. A user-based formative evaluation was conducted to assess the new functions of the cross-media annotation system and to explore their influence on students' note-taking behavior and performance. The results show that the new functions may facilitate the retention of key concepts of the paper textbooks and may improve knowledge construction based on explicit learning goals. (Contains 1 table and 7 figures.)

In a study of notetaking in university courses, we found that the large majority of students prefer paper to computer-based media like Tablet PCs for taking notes and making annotations. Based on this finding, we developed CoScribe, a concept and system which supports students in making collaborative handwritten annotations on printed lecture slides. It includes mechanisms for the paper-based sharing and semantic tagging of annotations and slides. Moreover, we present a novel visualization of shared handwritten annotations providing an integrated access to annotations from all learners. The results of a user study indicate that CoScribe efficiently supports student annotation and can be easily integrated into current annotation practice. (Contains 10 figures.)

The National Joint Committee on Learning Disabilities (NJCLD) strongly supports comprehensive assessment and evaluation of students with learning disabilities by a multidisciplinary team for the identification and diagnosis of students with learning disabilities. Comprehensive assessment of individual students requires the use of multiple data sources. These sources may include standardized tests, informal measures, observations, student self-reports, parent reports, and progress monitoring data from response-to-intervention (RTI) approaches (NJCLD, 2005). Reliance on any single criterion for assessment or evaluation is not comprehensive, nor is a group assessment, such as universal screening or statewide academic assessment tests, sufficient for comprehensive assessment or evaluation. This paper is intended to inform administrators, educators, parents, and others concerned about the effective identification and education of students with learning disabilities about the components, processes, and participants necessary for comprehensive assessment and evaluation, as well as optimal practices that should further enhance the education of students with learning disabilities. The NJCLD has long recognized that inappropriate assessment and evaluation practices may result in questionable incidence rates for learning disabilities (NJCLD, 2001a). Similarly, the NJCLD (2001a, 2001b) has provided a solid foundation for addressing the issues of assessment, evaluation, identification, and eligibility of students with learning disabilities. (Contains 1 footnote.)

Calls from policymakers to assimilate immigrants through English literacy have grown urgent. Yet the 2007 U.S. Census has reported that one in five U.S. residents speaks a language other than English at home. What's more, new immigrants often settle in long-standing immigrant communities in which these non-English languages are the lingua franca. These demographic trends call for a reconceptualization of the problematic relationship of literacy to immigrant assimilation. To whom, precisely, are immigrants assimilating, especially in multi-ethnic communities? And how exactly does literacy, especially biliteracy, shape this process? Through an ethnographic investigation of how two different immigrant groups form biliterate partnerships in the quest for legal immigration papers, this essay examines how literacy and assimilation function in light of the changing writing demands of contemporary immigrant life. (Contains 8 notes.)