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It is the responsibility of each organization, including private practice businesses, to maintain a comprehensive medical records retention policy. While registered dietitian nutritionists (RDNs) are qualified and competent business owners, navigating through the challenges of proper medical record management can be difficult without a sound policy. A comprehensive medical record retention policy consists of 4 major components: creation, utilization, maintenance, and destruction as well as a retention schedule. Successful implementation of a comprehensive medical record retention policy promotes positive clinician-patient interaction and avoidance of potential legal ramifications., (Copyright © 2021 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: A home-based record (HBR) is a health document kept by the patient or their caregivers, rather than by the health care facility. HBRs are used in 163 countries, but they have not been implemented universally or consistently. Effective implementation maximizes both health impacts and cost-effectiveness. We sought to examine this research-to-practice gap and delineate the facilitators and barriers to the effective implementation and use of maternal and child health HBRs especially in low- and middle-income countries (LMICs)., Methods: Using a framework analysis approach, we created a framework of implementation categories in advance using subject expert inputs. We collected information through 2 streams. First, we screened 69 gray literature documents, of which 18 were included for analysis. Second, we conducted semi-structured interviews with 12 key informants, each of whom had extensive experience with HBR implementation. We abstracted the relevant data from the documents and interviews into an analytic matrix. The matrix was based on the initial framework and adjusted according to emergent categories from the data., Results: We identified 8 contributors to successful HBR implementation. These include establishing high-level support from the government and ensuring clear communication between all ministries and nongovernmental organizations involved. Choice of appropriate contents within the record was noted as important for alignment with the health system and for end user acceptance, as were the design, its physical durability, and timely redesigns. Logistical considerations, such as covering costs sustainably and arranging printing and distribution, could be potential bottlenecks. Finally, end users' engagement with HBRs depended on how the record was initially introduced to them and how its importance was reinforced over time by those in leadership positions., Conclusions: This framework analysis is the first study to take a more comprehensive and broad approach to the HBR implementation process in LMICs. The findings provide guidance for policy makers, donors, and health care practitioners regarding best implementation practice and effective HBR use, as well as where further research is required., (© Mahadevan and Broaddus-Shea.)

Objective: To determine the reliability of the Social Security Death Master File (DMF) after the November 2011 changes limiting the inclusion of state records., Data Sources: Secondary data from the DMF, New York State (NYS) and New Jersey (NJ) Vital Statistics (VS), and institutional data warehouse., Study Design: Retrospective study. Two cohorts: discharge date before November 1, 2011, (pre-2011) or after (post-2011). Death in-hospital used as gold standard. NYS VS used for out-of-hospital death. Sensitivity, specificity, Cohen's Kappa, and 1-year survival calculated., Data Collection Methods: Patients matched to DMF using Social Security Number, or date of birth and Soundex algorithm. Patients matched to NY and NJ VS using probabilistic linking., Principal Findings: 97 069 patients January 2007-March 2016: 39 075 pre-2011; 57 994 post-2011. 3777 (3.9 percent) died in-hospital. DMF sensitivity for in-hospital death 88.9 percent (κ = 0.93) pre-2011 vs 14.8 percent (κ = 0.25) post-2011. DMF sensitivity for NY deaths 74.6 percent (κ = 0.71) pre-2011 vs 26.6 percent (κ = 0.33) post-2011. DMF sensitivity for NJ deaths 62.6 percent (κ = 0.64) pre-2011 vs 10.8 percent (κ = 0.15) post-2011. DMF sensitivity for out-of-hospital death 71.4 percent pre-2011 (κ = 0.58) vs 28.9 percent post-2011 (κ = 0.34). Post-2011, 1-year survival using DMF data was overestimated at 95.8 percent, vs 86.1 percent using NYS VS., Conclusions: The DMF is no longer a reliable source of death data. Researchers using the DMF may underestimate mortality., (© Health Research and Educational Trust.)

This study aims to analyze the behavior changes of health workers in township hospitals by exploring their individual service, health information utilization, and health information exchange before and after intervention.A cross-sectional survey was conducted from September, 2016 to December, 2016 in Qianjiang city, Hubei Province, China. A total of 432 township hospital health workers were investigated from 12 township hospitals. t test and chi-square test were adopted in the difference analysis to compare the behavior changes and factors of the control and intervention groups before and after intervention. t test and U test were used to analyze the behaviors and the key impact factors of health workers in township hospitals. The hypothesis test of the behavior changes in the township hospitals were analyzed using the partial least squares (PLS) method.No significant difference was observed between the control and intervention groups of health workers in township hospitals. Significant differences were observed in the behavior attitude (BA), perceived behavior control (PBC), behavior intention (BI), and behaviors of information utilization and exchange in the intervention group. A significant difference was observed in the indicators of subjective norm (SN), BI, and behaviors with respect to information exchange. A large increment was observed in the intervention group. Based on results of PLS, the individual service, health information utilization, and health information exchange established relationships with BA, SN, PBC, and BI to a certain degree.A cause and effect relationship can be observed among BA, SN, PBC, BI, and behaviors of health workers in the township hospitals. BI can promote behavior changes among township hospital health workers. Moreover, different behaviors are demonstrated by different people because of BA, SN, PBC, and BI. The results of this study can contribute to improving the feasibility, pertinence, and effects of health service, and can serve as the guide in understanding health workers' behaviors.

Anesthesia information management systems (AIMS) have evolved from simple, automated intraoperative record keepers in a select few institutions to widely adopted, sophisticated hardware and software solutions that are integrated into a hospital's electronic health record system and used to manage and document a patient's entire perioperative experience. AIMS implementations have resulted in numerous billing, research, and clinical benefits, yet there remain challenges and areas of potential improvement to AIMS utilization. This article provides an overview of the history of AIMS, the components and features of AIMS, and the benefits and challenges associated with implementing and using AIMS. As AIMS continue to proliferate and data are increasingly shared across multi-institutional collaborations, visual analytics and advanced analytics techniques such as machine learning may be applied to AIMS data to reap even more benefits.

Introduction: Many health services researchers are interested in assessing long term, individual physician treatment patterns, particularly for cancer care. In 2007, Medicare changed the physician identifier used on billed services from the Unique Physician Identification Number (UPIN) to the National Provider Identifier (NPI), precluding the ability to use Medicare claims data to evaluate individual physician treatment patterns across this transition period., Methods: Using the 2007-2008 carrier (physician) claims from the linked Surveillance, Epidemiology and End Results (SEER) cancer registry-Medicare data and Medicare's NPI and UPIN Directories, we created a crosswalk that paired physician NPIs included in SEER-Medicare data with UPINs. We evaluated the ability to identify an NPI-UPIN match by physician sex and specialty., Results: We identified 470,313 unique NPIs in the 2007-2008 SEER-Medicare carrier claims and found a UPIN match for 90.1% of these NPIs (n=423,842) based on 3 approaches: (1) NPI and UPIN coreported on the SEER-Medicare claims; (2) UPINs reported on the NPI Directory; or (3) a name match between the NPI and UPIN Directories. A total of 46.6% (n=219,315) of NPIs matched to the same UPIN across all 3 approaches, 34.1% (n=160,277) agreed across 2 approaches, and 9.4% (n=44,250) had a match identified by 1 approach only. NPIs were paired to UPINs less frequently for women and primary care physicians compared with other specialists., Discussion: National Cancer Institute has created a crosswalk resource available to researchers that links NPIs and UPINs based on the SEER-Medicare data. In addition, the documented process could be used to create other NPI-UPIN crosswalks using data beyond SEER-Medicare.

Aim: To clinically evaluate a type of patented automated anesthesia cart in medication administrations in anesthesia., Materials and Methods: This was a prospectively randomized open label clinical trial. In 10 designated operating suits in the First Affiliated Hospital of Zhengzhou University, in China. 1066 cases originated from 10,812 medication administrations in anesthesia were randomized. 78 registered anesthesiologists managed the medication. The patients received medication administrations in anesthesia with either an automated or a conventional manual cart. American Society of Anesthesiologists (ASA) score, sex, duration of anesthesia and surgical specialty, errors in administration of medications (incorrect medication given (substitution), medication not given (omission) and drug recordings errors"), compliance and satisfaction were recorded., Results: The total error rate was 7.3% with the automated anesthesia carts (1 in 14 administrations) and 11.9% with conventional manual carts (1 in 8 administrations). Automated anesthesia carts significantly reduced the drug recording error rate compared to conventional manual carts (P<0.01). However, no significant difference of substitution or errors omission errors was found between groups of automated anesthesia carts and conventional manual carts. The anesthesiologists' compliance with the automated anesthesia carts was unsatisfactory, and all the errors in medication recordings with the automated anesthesia carts were due to the incorrect use of the carts. Most of the participating anesthesiologists preferred the automated anesthesia carts (P<0.05)., Conclusions: The utilization of automated anesthesia carts reduced the drug recording errors in medication administrations of anesthesia., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose/objective: With an elderly and chronically ill patient population visiting the emergency department, it is important to know patients' wishes regarding care preferences and advanced directives. Ohio law states DNR orders must be transported with the patient when they leave an extended care facility (ECF). We reviewed the charts of ECF patients to evaluate which patients presenting to the ED had their DNR status recognized by the physician and DNR orders that were made during their hospital stay., Methods: We prospectively enrolled patients presenting from ECFs to the ED, blinding the treating team to the purpose. We did a chart review for the presence of a DNR form, demographic data and acknowledgement of the DNR forms., Results: Fifty patients were enrolled in this study. The mean age was 77.6years and 56% were female. Twenty-eight percent had a DNR order transported to the ED, but 68% had a DNR preference noted in their ECF notes. Registration only noted an advanced directive on 32% of patients (p=0.09). Eighteen percent had a DNR noted by the ED physician (p=0.42). Sixteen percent of patients had a DNR order written by an ED physician while 28% had a DNR order written by a non-ED physician during their inpatient evaluation. Thirty percent had a palliative care consult while in the hospital, but there was no significant association between DNR from the ECF and these consults., Conclusions: Hospital staff did a poor job of noting DNR preferences and ECFs were inconsistent with sending Ohio DNR forms., (Copyright © 2017. Published by Elsevier Inc.)

The unpredictability of unscheduled emergency dental care carries its own clinical, communication and management challenges with associated medico-legal risks. Providing emergency dental treatment for unfamiliar patients in an unfamiliar environment amplifies the hidden pitfalls which failure to avoid can create potentially damaging critical incidents in a practitioner's professional life. These are preferably avoided through consistent attention to best practice and risk management. Day to day processes, such as excellent record-keeping, valid consent and effective communication are under the spotlight in the event that a patient complains, raises a concern with a regulator or seeks compensation following alleged negligent care. This paper aims to highlight the dento-legal pitfalls that may be pertinent in such a challenging situation.

Background The availability of clinical information and a pertinent clinical question can improve the diagnostic accuracy of the imaging process. Purpose To examine if an electronic request form forcing referring clinicians to provide separate input of both clinical information and a clinical question can improve the quality of the request. Material and Methods A total of 607 request forms in the clinical worklists for a computed tomography (CT) scan of the thorax, the abdomen or their combination, were examined. Using software of our own making, we examined the presence of clinical information and a clinical question before and after the introduction of a new, more compelling order method. We scored and compared the quality of the clinical information and the clinical question between the two systems and we examined the effect on productivity. Results Both clinical information and a clinical question were present in 76.7% of cases under the old system and in 95.3% under the new system ( P < 0.001). Individual characteristics of the clinical information and the clinical question however, with the exception of incompleteness, showed little improvement under the new system. There was also no significant difference between the two systems in the number of requests requiring further search. Conclusion The introduction of electronic radiology request forms compelling referring clinicians to provide separate input of clinical information and a clinical question provides only limited benefit to the quality of the request. Raising awareness among clinicians of the importance of a well-written request remains essential.

Background: The accurate recording of findings in clinical medicolegal cases is important, yet the current J88 form used for this purpose in South Africa has been reported to have many flaws. In addition, there are reports of poor completion of the form, which could in part be due to its poor design and clarity., Objective: To describe the process that was undertaken to revise the current J88 form., Methods: A repetitive consultative process was used to revise the current J88 form and to obtain inputs from relevant government institutions., Results: A brief outline of the changes that have been made to the current J88 form and the reasons why these changes were proposed by national experts is provided., Conclusion: The revised J88 form will provide clearer guidance to healthcare providers on the completion of necessary information in an expedited fashion. It is hoped that the form will soon be approved by the necessary government institutions.

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI ® contents collaborated with some quality centred hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI ® " developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI ® contents. It is important to identify the problem of the volatility of the patients' data, conditions and some situation. We developed a survey tool of nursing documents using NursingNAVI ® Content for quality evaluation of nursing observation. We recommended some hospitals to use this survey tool. Fifteen hospitals participated the survey using this tool. It is estimated that the volatilizing situation. A hospital which don't participate this survey, knew the result. So the hospital decided to use NursingNAVI ® contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.

Rationale and Objectives: On-service clinical learning is a mainstay of radiology education. However, an accurate and timely case log is difficult to keep, especially in the absence of software tools tailored to resident education. Furthermore, volume-related feedback from the residency program sometimes occurs months after a rotation ends, limiting the opportunity for meaningful intervention., Materials and Methods: We surveyed the residents of a single academic institution to evaluate the current state of and the existing need for tracking interpretation volume. Using the results of the survey, we created an open-source automated case log software. Finally, we evaluated the effect of the software tool on the residency in a 1-month, postimplementation survey., Results: Before implementation of the system, 89% of respondents stated that volume is an important component of training, but 71% stated that volume data was inconvenient to obtain. Although the residency program provides semiannual reviews, 90% preferred reviewing interpretation volumes at least once monthly. After implementation, 95% of the respondents stated that the software is convenient to access, 75% found it useful, and 88% stated they would use the software at least once a month. The included analytics module, which benchmarks the user using historical aggregate average volumes, is the most often used feature of the software. Server log demonstrates that, on average, residents use the system approximately twice a week., Conclusions: An automated case log software system may fulfill a previously unmet need in diagnostic radiology training, making accurate and timely review of volume-related performance analytics a convenient process., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Background: Administrative or quality improvement registries may or may not contain the elements needed for investigations by trauma researchers. International Classification of Diseases Program for Injury Categorisation (ICDPIC), a statistical program available through Stata, is a powerful tool that can extract injury severity scores from ICD-9-CM codes. We conducted a validation study for use of the ICDPIC in trauma research., Methods: We conducted a retrospective cohort validation study of 40,418 patients with injury using a large regional trauma registry. ICDPIC-generated AIS scores for each body region were compared with trauma registry AIS scores (gold standard) in adult and paediatric populations. A separate analysis was conducted among patients with traumatic brain injury (TBI) comparing the ICDPIC tool with ICD-9-CM embedded severity codes. Performance in characterising overall injury severity, by the ISS, was also assessed., Results: The ICDPIC tool generated substantial correlations in thoracic and abdominal trauma (weighted κ 0.87-0.92), and in head and neck trauma (weighted κ 0.76-0.83). The ICDPIC tool captured TBI severity better than ICD-9-CM code embedded severity and offered the advantage of generating a severity value for every patient (rather than having missing data). Its ability to produce an accurate severity score was consistent within each body region as well as overall., Conclusions: The ICDPIC tool performs well in classifying injury severity and is superior to ICD-9-CM embedded severity for TBI. Use of ICDPIC demonstrates substantial efficiency and may be a preferred tool in determining injury severity for large trauma datasets, provided researchers understand its limitations and take caution when examining smaller trauma datasets., (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.)

Background: Communication failures between clinicians and dermatopathologists are prevalent. Our primary objective was to characterize the concerns and challenges of dermatopathologists posed by incomplete or inaccurate clinical information in the skin biopsy requisition form., Methods: An explanatory sequential, mixed-methods study design comprised of a survey sent to 1103 members of the American Society of Dermatopathology (ASDP), followed by two focus group sessions., Results: A total of 54% (598/1103) of dermatopathologists completed the questionnaire. Most dermatopathologists (80%; 436/548) viewed their roles to be providers of histopathological diagnosis and a report that is clinically meaningful. Paper or electronic requisition forms were the most common communication method (85%; 458/541) and were associated with the highest rates of dissatisfaction in 36% (193/537) of respondents. Inadequacy of specimens emerged as an important factor influencing judgment of the quality of provided clinical information. 44.7% (261/584) of dermatopathologists spent 30 minutes or more on average every day searching for relevant clinical information to assist with their histopathologic interpretation., Conclusion: ASDP dermatopathologists expressed significant dissatisfaction with the quality of clinical information in the requisition form and the time spent gathering information necessary for accurate, timely and clinically meaningful diagnosis. These findings have implications for the quality, safety and efficiency of dermatologic care., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI® contents collaborated with some quality centered hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI®" developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI® contents. A hospital decided to use NursingNAVI® contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.

A patient's notes, assessments, care plans and letters are all evidence of the care and treatment they received. This CPD article highlighted how patient records are clinical tools that act as evidence of care, or the lack of it, and are relevant to every nurse's practice.

Background: Electronic care records (ECRs) for cystic fibrosis (CF) provide a basis for accurate, reliable capture of clinical measures and interventions, and epidemiological trends, providing the basis for improved efficiency and patient safety., Methods: A primary care system was modified for hospital use and clinical codes devised for all aspects of CF care. Performance and usability were assessed., Results: Of a total of 620 patients 619 consented to their data being recorded in the system. Five hundred and twenty three new codes were created and embedded behind 60 new templates. Following introduction of ECR, completion of annual assessments increased from 43% to 92%, retrieval of drug costs rose significantly and time to correspondence with primary care fell from 34days to <2days. Staff satisfaction was high., Conclusion: The system is fully operational allowing the unit to function as a paperless service. Efficiencies of staffing activity, process management and cost retrievals are evident. Sharing of coding structures is important in future care., (Copyright © 2014 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Electronic medical records (EMRs) can be a valuable tool in evaluating interventions involving faith-based institutions. Working with EMRs is complex. Methodological designs that can be used by public health and health administrators to assess the effectiveness of interventions are lacking. The study team conducted a formative evaluation of the Congregational Health Network (CHN) using propensity matching and Cox proportional hazard models to examine health outcomes and readmission rates. Along with CHN's relevance in addressing the needs of the most vulnerable population, factors are discussed that must be taken into consideration when designing such methodologies as well as limitations that merit attention from public health researchers and hospital administrators interested in conducting a formative evaluation using existing data to track the effectiveness of an intervention.

Objective: To provide a case report of barriers and promoters to implementing a health information exchange (HIE) tool that supports patient transfers between hospitals and skilled nursing facilities., Methods: A multi-disciplinary team conducted semi-structured telephone and in-person interviews in a purposive sample of HIE organizational informants and providers in New York City who implemented HIE to share patient transfer information. The researchers conducted grounded theory analysis to identify themes of barriers and promoters and took steps to improve the trustworthiness of the results including vetting from a knowledgeable study participant., Results: Between May and October 2011, researchers recruited 18 participants: informaticians, healthcare administrators, software engineers, and providers from a skilled nursing facility. Subjects perceived the HIE tool's development a success in that it brought together stakeholders who had traditionally not partnered for informatics work, and that they could successfully share patient transfer information between a hospital and a skilled nursing facility. Perceived barriers included lack of hospital stakeholder buy-in and misalignment with clinical workflows that inhibited use of HIE-based patient transfer data. Participants described barriers and promoters in themes related to organizational, technical, and user-oriented issues. The investigation revealed that stakeholders could develop and implement health information technology that technically enables clinicians in both hospitals and skilled nursing facilities to exchange real-time information in support of patient transfers. User level barriers, particularly in the emergency department, should give pause to developers and implementers who plan to use HIE in support of patient transfers., Conclusions: Participants' experiences demonstrate how stakeholders may succeed in developing and piloting an electronic transfer form that relies on HIE to aggregate, communicate, and display relevant patient transfer data across health care organizations. Their experiences also provide insights for others seeking to develop HIE applications to improve patient transfers between emergency departments and skilled nursing facilities.

Physician practices worked feverishly in 2013 to thoroughly comprehend the HIPAA Omnibus, then to educate all staff that work with private health information, and finally to implement the procedures required for compliance with the new final rule. But practices must avoid complacency in the wake of last year's successful compliance efforts. They must continue to manage and monitor the rule's key issues, paying particular attention to their electronic health records system, which can be a weak link in the compliance chain. Other areas of focus for physician practices in 2014 are the appropriate destruction of obsolete medical records and the documentation of all compliance efforts.

Background: Radiological information technology (IT) is nowadays one of many components of an integrated hospital IT structure., Objective: This review article is concerned with the challenges of a comprehensive and complete integration of all documented information and communication of all medical disciplines in a hospital in the electronic patient records. Special attention is paid to the role of radiology and the interface between radiological and clinical systems., Perspectives: The utilization of the documented data paying special attention to the requirements of data protection is a core aim for the further development of electronic patient records in the University Hospital Hamburg-Eppendorf in the coming years.

Linking interface terminologies (IT) to reference terminologies (RT) in flow of terminologies may allow health information system to be both usable and interoperable. Two French university hospitals worked independently on such a flow from the prescription of lab-test to the display of the corresponding results. The aim of this study was to evaluate the transmission of information in these two hospitals communication. An expert, supported by natural language processing tool, created the gold standard link between the 2 prescription ITs i.e. the terms that share the same meaning. A semantic pathway was defined to allow the mapping of one prescription IT to the other, through LOINC® and SNOMED®, the RT chosen by each hospital, respectively. The capacity of the semantic pathway to identify the correct links was computed. The expert found 218 links between the 2 prescription ITs (containing 580 and 374 terms that are linked to RT). The semantic pathway correctly identifies 96 of these links (44.0% [37.4-50.6]). The recall was not as good as expected, even though the semantic pathway was created in order to maximize it. Using different RT in different hospitals is not an efficient solution. The use of LOINC® seems to be preferable as a RT for prescription.

Purpose: The present study aims to develop a simple, reliable and easy tool enabling clinicians to codify the major part of individualized medical details (patient history and findings of physical examination) quickly and easily in routine medical practice, by entering data to a purpose-built software application, using structure data elements and detailed medical illustrations., Materials and Methods: We studied medical records of 9,320 patients and we extracted individualized medical details. We recorded the majority of symptoms and the majority of findings of physical examination into the system, which was named IMPACT® (Intelligent Medical Patient Record and Coding Tool). Subsequently the system was evaluated by clinicians, based on the examination of 1206 patients., Results: The evaluation results showed that IMPACT® is an efficient tool, easy to use even under time-pressing conditions., Conclusion: IMPACT® seems to be a promising tool for illustration-guided, structured data entry of medical narrative, in electronic patient records.

In Denmark, there are plans for establishing a national decision support system, providing on-line support for physicians during drug prescribing. This includes establishment of a national database containing information about each patient's drug allergies. Allergy information already exists in medication modules in hospital systems and primary care systems and thus constitutes a potential source for the national allergy database. This paper reports an analysis of local data structure, content and registration policies with the aim to re-use existing allergy data. The result of the analysis is that due to lack of harmonisation most existing cannot be re-used in the national database. The paper propose a common dataset for allergy data where national and international standards were considered.

The chief complaint is a patient's self-reported primary reason for presenting for medical care. The clinical utility and analytical importance of recording chief complaints have been widely accepted in highly developed emergency care systems, but this practice is far from universal in global emergency care, especially in limited-resource areas. It is precisely in these settings, however, that the use of chief complaints may have particular benefit. Chief complaints may be used to quantify, analyze, and plan for emergency care and provide valuable information on acute care needs where there are crucial data gaps. Globally, much work has been done to establish local practices around chief complaint collection and use, but no standards have been established and little work has been done to identify minimum effective sets of chief complaints that may be used in limited-resource settings. As part of the Academic Emergency Medicine consensus conference, "Global Health and Emergency Care: A Research Agenda," the breakout group on data management identified the lack of research on emergency chief complaints globally-especially in low-income countries where the highest proportion of the world's population resides-as a major gap in global emergency care research. This article reviews global research on emergency chief complaints in high-income countries with developed emergency care systems and sets forth an agenda for future research on chief complaints in limited-resource settings., (© 2013 by the Society for Academic Emergency Medicine.)

In the attempt to harmonize clinical practices between different French transplantation centers, the French Society of Bone Marrow Transplantation and Cell Therapy (SFGM-TC) set up the third annual series of workshops which brought together practitioners from all member centers and took place in October 2012 in Lille. The main aim of this session was to describe the relations between the national transplant coordination office of the French registry and local stem cell transplantation coordinators throughout France., (Copyright © 2013. Published by Elsevier SAS.)

Typically general wards and intensive care units (ICU) have very different labor organizations, structures and IT-systems in Germany. There is a need for coordination, because of the different working arrangements. Our team investigated the interface between ICU and general ward and especially the respective information transfer in the University hospital in Erlangen (Bavaria, Germany). The research team used a combination of interviews, observations and the analysis of transfer records and forms as part of a methodical triangulation. We identified 41 topics, which are discussed or presented in writing during the handover. In a second step, we investigate the requirements of data transmission in expert interviews. A data transfer concept from the perspective of the nurses and physicians was developed and we formulated recommendations for improvements of process and communication for this interface. Finally the data transfer concept was evaluated by the respondents.

Introduction: Electronic health records (EHRs) are receiving a lot of attention for their potential to improve care., Objective: To develop and implement EHRs in the antenatal clinic (ANC) of a teaching and referral hospital in Western Kenya., Results: A multidisciplinary team developed a phased implementation of EHRs in the ANC as part of a CDC-funded effort to develop and implement primary care EHRs in lower level and referral facilities in Kenya comprising a clinic registration system and initial- and return-visit encounter forms that captured and reported data required for reporting. This was successfully done, the EHR fully implemented in the ANC including a reminder system to enhance adherence to care guidelines., Conclusions: It is possible to implement EHRs in a referral hospital ANC.

One year ago the portal of Medical Data Models (http://medical-data-models.org) was presented as a resource for the scientific community. As of November 2012 there are approximately 3,300 forms with 102,000 items available in the CDISC ODM format. First descriptive analyses regarding form metadata demonstrate the capability of such a repository to identify commonly used medical concepts. Most common items are administrative attributes which indicates that more clinical information are needed to increase the secondary use of data documented within these forms.

Objectives: A quantitative decision-support tool (DST), using a combination of selected human physical attributes as identification elements, was developed to facilitate body identification in mass fatality incidents, particularly in settings with limited availability of technological resources and forensic expertise., Methods: To construct the DST, the external biological attributes of interest were first selected. A process was then developed to guide collection of the selected categories of attributes and record them into objective antemortem (AM) and postmortem (PM) records. Finally, a framework for assessing the similarity between confronting PM-AM attribute records was established. The DST evaluates the similarities between each set of like attributes in the AM and PM records being compared. It then computes an overall similarity score for each evaluated AM record that was compared to a selected PM record. The AM record with the highest score represents the highest probable match, with the PM file selected for the comparison., Results: Multiple simulations across a range of mass fatality situations demonstrated the effectiveness of the DST in the experimental setting., Conclusions: The developed DST may provide authorities with a method for expediting body identification without completely eliminating any missing person file from consideration. Under specific circumstances, this method may reduce the need for technologically sophisticated forensic identification techniques (eg, dental records, fingerprints, and DNA). At a minimum, it should facilitate the efficiency of the current technological matching process.

County Durham and Darlington's implementation of an electronic health record across community health services provided an ideal opportunity for health visitors to take the lead in enhancing the system to reflect their paper clinical record. Practitioners' concerns, fears and anxieties in relation to confidentiality and professional accountability resulted in the project being further developed to include the employment of three full-time clinical IT facilitators. These were experienced health visitors and 'IT champions' with a sound knowledge of information governance with a specific remit to provide clinical support and supervision to health visitors in electronic clinical record keeping. These practitioners were instrumental in developing the system and proved the key to the project's success and ensuring that the electronic record was embedded into health visiting practice to improve the quality of patient care.

In this research in progress, a reference model for the use of electronic patient record (EPR) systems in oncology is described. The model, termed CICERO, comprises technical and functional components, and emphasises usability, clinical safety and user acceptance. One of the functional components of the model-an electronic document and records management (EDRM) system-is monitored in the course of its deployment at a leading oncology centre in the UK. Specifically, the user requirements and design of the EDRM solution are described.The study is interpretative and forms part a wider research programme to define and validate the CICERO model. Preliminary conclusions confirm the importance of a socio-technical perspective in Onco-EPR system design.