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Background: There are limited data on the accuracy of documentation of trauma activations in the electronic medical record (EMR) compared with a paper chart. Our primary objective was to compare the accuracy of documentation between a paper chart and EMR in pediatric trauma., Methods: We studied video recordings of trauma activations at a level 1 pediatric trauma center. These videos were reviewed, and data points collected were used to compare accuracy of documentation in the paper chart and EMR., Results: We reviewed 106 videos with 1614 data points collected. Of those, 805 data points were compared with their corresponding paper chart with 710 data points correctly documented (88.2%). The remaining 809 data points were compared with their corresponding electronic documentation after implementation of the EMR with 681 data points being correctly documented (84.2%). Overall, we found that paper documentation was significantly more accurate than the EMR (p = 0.019). When analyzed in subcategories of pre-arrival information, primary and secondary survey, and interventions, paper documentation was found to be significantly more accurate than the EMR for components of the primary and secondary survey (87.3% vs. 80.4%, p = 0.001). There was no significant difference in accuracy of documentation between paper and EMR for pre-arrival information (88.1% vs. 89.4%) or interventions (90.3% vs. 92%)., Conclusion: Documentation of trauma activations is overall more accurate using a paper chart than EMR. Although documentation was accurate for most categories using both a paper chart and EMR, we found significantly less accuracy in documentation of the primary and secondary survey in the EMR., Competing Interests: Declaration of Competing Interest The authors have no disclosures or conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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.

Aims and Objectives: To explore organisation-wide experiences of person-centred care and risk assessment practices using existing healthcare organisation documentation., Background: There is increasing emphasis on multidimensional risk assessments during hospital admission. However, little is known about how nurses use multidimensional assessment documentation in clinical practice to address preventable harms and optimise person-centred care., Design: A qualitative descriptive study reported according to COREQ., Methods: Metropolitan tertiary hospital and rehabilitation hospital servicing a population of 550,000. A sample of 111 participants (12 patients, 4 family members/carers, 94 nurses and 1 allied health professional) from a range of wards/clinical locations. Semi-structured interviews and focus groups were conducted at two time points. The audio recording was transcribed, and an inductive thematic analysis was used to provide insight from multiple perspectives., Results: Three main themes emerged: (1) 'What works well in practice' included: efficiency in the structure of the documentation; the Introduction, Situation, Background Assessment, Recommendation (ISBAR) framework and prompting for clinical decision-making were valued by nurses; and direct patient care is always prioritised. (2) 'What does not work well in practice': obtaining the patient's signature on daily care plans; multidisciplinary (MDT) involvement; duplication of paperwork and person-centred goals are not well-captured in care plan documentation. (3) 'Experience of care'; satisfaction of person-centred care; communication in the MDT was important, but sometimes insufficient; patients had variable involvement in their daily care plan; and inadequate integration of care between MDT team which negatively impacted patients., Conclusions: Efficient and streamlined documentation systems should herald feedback from nurses to address their clinical workflow needs and can support, and capture, their decision-making that enables partnership with patients to improve the individualisation of care provision., Relevance to Clinical Practice: The integration of effective MDT involvement in clinical documentation was problematic and resulted in unmet supportive care from the patient's perspective., (© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Objective: We hypothesized that a paper documentation and discharge bundle can expedite patient care during an influenza-related surge., Methods: Retrospective cohort study of low-acuity patients younger than 21 years surging into a pediatric emergency department between January and March 2018 with influenza-like illness. Patient visits documented using a paper bundle were compared with those documented in the electronic medical record on the same date of visit. The primary outcome of interest was time from physician evaluation to discharge for patient visits documented using the paper bundle compared with those documented in the electronic medical record. Secondary outcome was difference in return visits within 72 hours. We identified patient and visit level factors associated with emergency department length of stay., Results: A total of 1591 patient visits were included, 1187 documented in the electronic health record and 404 documented using the paper bundle. Patient visits documented using the paper bundle had a 21% shortened median time from physician evaluation to discharge (41 minutes; interquartile range, 27-62.8 minutes) as compared with patient visits documented in the electronic health record (52 minutes; interquartile range, 35-61 minutes; P < 0.001). There was no difference in return visits (odds ratio, 0.7; 95% confidence interval, 0.2, 2.2)., Conclusions: Implementation of paper charting during an influenza-related surge was associated with shorter physician to discharge times when compared with patient visits documented in the electronic health record. A paper bundle may improve patient throughput and decrease emergency department overcrowding during influenza or coronavirus disease-related surge., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR). Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery. Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P  = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P  < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P  < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P  = 0.032). Conclusion The EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record. What is known about the topic? Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record. What does this paper add? Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement. What are the implications for practitioners? The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.

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.

Purpose: To evaluate the effect of electronic and paper-based standardized nursing care plans (SNCPs) use on quality of nurses' documentation., Methods: Using quasi-experimental design, two wards were grouped into electronic and paper-based wards. Nurses were trained to use electronic- and paper-based SNCPs for care-planning and documentation. Data was collected before, 3, and 6 months postintervention and analyzed with SPSS version 20., Findings: There was improvement in documentation quality in the two wards after introducing SNCPs with higher quality scores in the electronic ward postintervention., Conclusion: Providing SNCPs in electronic and paper formats is critical to improving nursing documentation., Implication for Nursing Practice: Adequate training and support for nurses are needed for successful implementation of SNCPs in electronic health records (EHRs) in developing nations., (© 2018 NANDA International, Inc.)

We investigate the sub-networks involved in education policy in Israel in recent years, using Mixed Methods Social Networks Analysis - drawn from combined analysis of qualitative and quantitative data. Our objective was to comprehensively explore the Israeli education policy network to deliver an understanding of its structure, actors, and relationships. Our research offers a descriptive, analytical, and interpretive account of the contemporary Israeli education policy sector, including the actors involved, central policy sub-networks and organizations, and their relationships. We analyze dependence relations within the sub-networks using Resource Dependency Theory and Policy Networks Typology. Our findings contribute to understanding the dynamics of Israeli education policy networks and their perceived influence on policy-making and enactment processes. To the international field of educational policy-related research, we introduce a novel category of policy network actors, previously unaddressed as a distinct type. We have termed this category 'Ethos networks' to characterize this group of actors and elaborate on its significance within the field. Additionally, we underline the importance of considering external societal and political factors in education policy-making.

Objective: Despite growing use of electronic health records, many resuscitation settings still use paper-based documentation. The fast-paced and safety-critical nature of trauma and medical resuscitation environments pose challenges for real-time documentation. This study aims to understand paper-based documentation practices and inform the design of efficient electronic documentation solutions for supporting safety-critical medical processes., Methods: Data were collected through in situ observations of nurse documenters during resuscitation events and postevent interviews with nurses. These data were analyzed using frequency distribution and qualitative, open-coding techniques. Data analysis focused on the following 3 main documentation factors: temporal distribution of documentation, total number of filled out sections on the paper flow sheet across all resuscitations, and completeness of documentation per resuscitation., Results: Findings from this study highlight the time-critical nature of these settings, showing that 74% of the documentation was completed within the first 15 minutes of the resuscitation. Some sections of the paper flow sheet were filled out more than others, and a few sections were left incomplete across all events. Interviews with nurses provided insight about documentation experiences in a fast-paced environment, including variable usage of flow sheet based on nurse experience level and patient scenarios, supplemental documentation mechanisms, and information needs and preferences., Conclusions: Several design implications are discussed to inform the design of effective electronic documentation systems. Design implications focus on layout structure, prepopulating items, section placement, and completion status of the flow sheet. Future plans for research focus on combining video review with in situ observations and conducting detailed interviews with nurses to better understand their documentation experiences and preferences., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

This paper investigates the role of admission forms in the regulation of asylum confinement in the second half of the nineteenth century. Taking the Toronto Lunatic Asylum as a case study it traces the evolution of the forms' content and structure during the first decades of this institution. Admission forms provide important material for understanding the medico-legal assessment of lunacy in a certain jurisdiction. First, they show how the description of insanity depended on a plurality of actors. Second, doctors were not necessarily required to indicate symptoms of derangement. Third, patients' relatives played a fundamental role in providing clinical information. From an historiographical perspective, this paper invites scholars to consider the function of standardized documents in shaping the written identity of patients.

Background: Inpatient nursing documentation facilitates multi-disciplinary team care and tracking of patient progress. In both high- and low- and middle-income settings, it is largely paper-based and may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed., Objective: To synthesise evidence on how paper-based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care., Design: A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA-ScR guidelines., Eligibility Criteria: We included studies that described the process of designing paper-based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019., Sources of Evidence: PubMed, CINAHL, Web of Science and Cochrane supplemented by free-text searches on Google Scholar and snowballing the reference sections of included papers., Results: 12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges., Conclusions: The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human-centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes., Relevance to Clinical Practice: Paper-based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation., (© 2020 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

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.)

Purpose: To assess time requirements for patient encounters and estimate after-hours demands of paper-based clinical workflows in ophthalmology., Design: Time-and-motion study with a structured survey., Methods: This 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., Results: Among 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., Conclusions: Paper-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., (Published by Elsevier Inc.)

BACKGROUND: The American College of Surgeons requires continuous process improvement review to maintain trauma center verification. Paper-based systems to monitor and track performance improvement are commonly used but can be inadequate to monitor concurrent ongoing improvement effectively. OBJECTIVE: To describe the implementation of an electronic process to capture and monitor performance improvement in near real time. METHODS: In 2020, a Midwestern U.S. Level I adult trauma center and a Level II pediatric trauma center's trauma programs transitioned from a paper to an electronic file-sharing system for performance improvement. We converted our primary, secondary, and tertiary review documentation into a single electronic performance improvement file stored on the institution's virtual hard drive, accessible to designated staff, allowing continuous real-time updates. RESULTS: The electronic file-sharing and monitoring process reinvigorated the team and enhanced performance improvement efforts, leading to increased efficiency through documentation and effective loop closure. Real-time monitoring allowed the trauma program to identify opportunities for improvement and enact timely action plans, including targeted performance improvement projects, department education, and ongoing training. CONCLUSION: We found that implementing an electronic file-sharing system enhanced the trauma team's ability to monitor and trend performance improvement in real time. [ABSTRACT FROM AUTHOR]

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.

Portfolios are used in midwifery education to provide students with a central place to store their accumulative evidence of clinical experience for initial registration in Australia. Portfolio formats can be paper-based or electronic. Anecdotal discussion between midwifery students in Queensland debated the best format to document the requirements for the Australian Nursing and Midwifery Accreditation Council (ANMAC) standard 8.11. Midwifery students using paper-based portfolios envisioned that an ePortfolio would be streamline, simple, safe to use, and able to be used anywhere with WIFI, while some students using an ePortfolio expressed a desire to have a paper-based portfolio as a hard copy. This situation called for evidence of a comparison to resolve the debate. The aim of this study was to investigate midwifery students' experiences of the benefits and challenges between paper-based and ePortfolios when compiling evidence to meet the requirements for initial registration as a midwife in Australia (ANMAC, 2014)., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group ( P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Introduction: In adults with a suspicion of peripheral bone infection, evidence-based guidelines in choosing the most accurate diagnostic strategy are lacking., Aim and Methods: To provide an evidence-based, multidisciplinary consensus document on the diagnostic management of adult patients with PBIs, we performed a systematic review of relevant infectious, microbiological, orthopedic, radiological, and nuclear medicine literature. Delegates from four European societies (European Bone and Joint Infection Society, European Society of Microbiology and Infectious Diseases, European Society or Radiology, and European Association of Nuclear Medicine) defined clinical questions to be addressed, thoroughly reviewed the literature pertinent to each of the questions, and thereby evaluated the diagnostic accuracy of each diagnostic technique. Inclusion of the papers per statement was based on a PICO (Population/problem - Intervention/indicator - Comparator - Outcome) question following the strategy reported by the Oxford Centre for Evidence-based Medicine. For each statement, the level of evidence was graded according to the 2011 review of the Oxford Centre for Evidence-based Medicine. All approved statements were addressed taking into consideration the available diagnostic procedures, patient acceptance, tolerability, complications, and costs in Europe. Finally, a commonly agreed-upon diagnostic flowchart was developed.

Background: For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking., Aim and Methods: To address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart., Results and Conclusion: The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM).

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.)

Artificial intelligence and machine learning technologies have a variety of applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. This position paper describes the American College of Physicians' (ACP) foundational positions and recommendations regarding the use of these technologies in the provision of health care. The foundation of these positions are principles in the ACP Ethics Manual. Internal medicine physicians are increasingly interacting with systems that implement artificial intelligence (AI) and machine learning (ML) technologies. Some physicians and health care systems are even developing their own AI models, both within and outside of electronic health record (EHR) systems. These technologies have various applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. With the growing availability of vast amounts of patient data and unprecedented levels of clinician burnout, the proliferation of these technologies is cautiously welcomed by some physicians. Others think it presents challenges to the patient–physician relationship and the professional integrity of physicians. These dispositions are understandable, given the "black box" nature of some AI models, for which specifications and development methods can be closely guarded or proprietary, along with the relative lagging or absence of appropriate regulatory scrutiny and validation. This American College of Physicians (ACP) position paper describes the College's foundational positions and recommendations regarding the use of AI- and ML-enabled tools and systems in the provision of health care. Many of the College's positions and recommendations, such as those related to patient-centeredness, privacy, and transparency, are founded on principles in the ACP Ethics Manual. They are also derived from considerations for the clinical safety and effectiveness of the tools as well as their potential consequences regarding health disparities. The College calls for more research on the clinical and ethical implications of these technologies and their effects on patient health and well-being. [ABSTRACT FROM AUTHOR]

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.)

Purpose: To compare accuracy and speed of keyboard and mouse electronic health record (EHR) documentation strategies with those of a paper documentation strategy., Design: Prospective cohort study., Methods: Three documentation strategies were developed: (1) keyboard EHR, (2) mouse EHR, and (3) paper. Ophthalmology trainees recruited for the study were presented with 5 clinical cases and documented findings using each strategy. For each case-strategy pair, findings and documentation time were recorded. Accuracy of each strategy was calculated based on sensitivity (fraction of findings in actual case that were documented by subject) and positive ratio (fraction of findings identified by subject that were present in the actual case)., Results: Twenty subjects were enrolled. A total of 258 findings were identified in the 5 cases, resulting in 300 case-strategy pairs and 77 400 possible total findings documented. Sensitivity was 89.1% for the keyboard EHR, 87.2% for mouse EHR, and 88.6% for the paper strategy (no statistically significant differences). The positive ratio was 99.4% for the keyboard EHR, 98.9% for mouse EHR, and 99.9% for the paper strategy (P < .001 for mouse EHR vs paper; no significant differences between other pairs). Mean ± standard deviation documentation speed was significantly slower for the keyboard (2.4 ± 1.1 seconds/finding) and mouse (2.2 ± 0.7 seconds/finding) EHR compared with the paper strategy (2.0 ± 0.8 seconds/finding). Documentation speed of the mouse EHR strategy worsened with repetition., Conclusions: No documentation strategy was perfectly accurate in this study. Documentation speed for both EHR strategies was slower than with paper. Further studies involving total physician time requirements for ophthalmic EHRs are required., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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.)

Introduction: Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations., Methods: The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n=200) was compared with a random sample of trauma resuscitations documented electronically (n=200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation., Results: The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P<.00), primary assessment (94% vs 88%, P<.036), arrival time of attending physician (98% vs 93.5%, P<.026), intravenous fluid volume in the emergency department (94% vs 88%, P<.036), and disposition (100% vs 89.5%, P<.00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P<.00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation., Discussion: Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations., (Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Background: Electronic medical records are becoming an integral part of healthcare delivery., Objective: The goal of this study was to compare paper documentation versus electronic medical record for non-traumatic chest pain to determine differences in time for physicians to complete medical records using paper versus electronic mediums. We also assessed physician satisfaction with the electronic format., Methods: We conducted this before-after study in a single large tertiary care academic emergency department. In the 'Before Period', stopwatches determined the time for paper medical recording. In the 'After Period', a template-based electronic medical record was introduced and the time for electronic recording was measured. The time to record in the before and after periods were compared using a two-sided t test. We surveyed physicians to assess satisfaction., Results: We enrolled 100 non-traumatic patients with chest pain in the before period and 73 in the after period. The documentation time was longer using electronic charting, (9.6±5.9 min vs 6.1±2.5 min; p<0.001). 18 of 20 physicians participating in the after period completed surveys. Physicians were not satisfied with the electronic patient recording for non-traumatic chest pain., Conclusions: This is the first study that we are aware of which compared paper versus electronic medical records in the emergency department. Electronic recording took longer than paper records. Physicians were not satisfied using this electronic record. Given the time pressures on emergency physicians, a solution to minimise the charting time using electronic medical records must be found before widespread uptake of electronic charting will be possible., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To evaluate the ability of an electronic system created at the University of Washington to accurately document prerecorded VF and pulseless electrical activity (PEA) cardiac arrest scenarios compared with the American Heart Association paper cardiac arrest record., Methods: 16 anaesthesiology residents were randomly assigned to view one of two prerecorded, simulated VF and PEA scenarios and asked to document the event with either the paper or electronic system. Each subject then repeated the process with the other video and documentation method. Five types of documentation errors were defined: (1) omission, (2) specification, (3) timing, (4) commission and (5) noise. The mean difference in errors between the paper and electronic methods was analysed using a single factor repeated measures ANOVA model., Results: Compared with paper records, the electronic system omitted 6.3 fewer events (95% CI -10.1 to -2.5, p=0.003), which represents a 28% reduction in omission errors. Users recorded 2.9 fewer noise items (95% CI -5.3 to -0.6, p=0.003) when compared with paper, representing a 36% decrease in redundant or irrelevant information. The rate of timing (Δ=-3.2, 95% CI -9.3 to 3.0, p=0.286) and commission (Δ=-4.4, 95% CI -9.4 to 0.5, p=0.075) errors were similar between the electronic system and paper, while the rate of specification errors were about a third lower for the electronic system when compared with the paper record (Δ=-3.2, 95% CI -6.3 to -0.2, p=0.037)., Conclusions: Compared with paper documentation, documentation with the electronic system captured 24% more critical information during a simulated medical emergency without loss in data quality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aims and Objectives: To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process., Background: The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122-1131)., Design: The project was a mixed-method, two-phase study that collected data from two sites., Methods: In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice., Results: Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration., Conclusions: We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation., Relevance to Clinical Practice: Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases., (© 2018 John Wiley & Sons Ltd.)