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[PMID]:29436810
[Au] Autor:Orlova A; Warner D; Rhodes H
[Ti] Título:Connecting Functional and Semantic Interoperability--The HIM Professional's Role in HIT Standardization.
[So] Source:J AHIMA;87(11):44-7, 2016 Nov-Dec.
[Is] ISSN:1060-5487
[Cp] País de publicação:United States
[La] Idioma:eng
[Mh] Termos MeSH primário: Troca de Informação em Saúde/normas
Gestão da Informação em Saúde/normas
Papel Profissional
Semântica
Integração de Sistemas
[Mh] Termos MeSH secundário: Acesso à Informação
Controle de Formulários e Registros/normas
Seres Humanos
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1803
[Cu] Atualização por classe:180301
[Lr] Data última revisão:
180301
[Sb] Subgrupo de revista:H
[Da] Data de entrada para processamento:180214
[St] Status:MEDLINE


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[PMID]:29406671
[Au] Autor:Chou E; Montroy T
[Ti] Título:Does Your Forms Committee Need a Facelift? Standardizing Best Practices for HIM-focused Committees--A Case Study in the Physician Practice Setting.
[So] Source:J AHIMA;88(2):32-5, 2017 02.
[Is] ISSN:1060-5487
[Cp] País de publicação:United States
[La] Idioma:eng
[Mh] Termos MeSH primário: Controle de Formulários e Registros/organização & administração
Gestão da Informação em Saúde/organização & administração
Comitê de Profissionais/organização & administração
[Mh] Termos MeSH secundário: Documentação
Seres Humanos
Modelos Organizacionais
Estudos de Casos Organizacionais
Pennsylvania
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1803
[Cu] Atualização por classe:180301
[Lr] Data última revisão:
180301
[Sb] Subgrupo de revista:H
[Da] Data de entrada para processamento:180207
[St] Status:MEDLINE


  3 / 7729 MEDLINE  
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[PMID]:29189048
[Au] Autor:Buckley BW; Daly L; Allen GN; Ridge CA
[Ad] Endereço:1 St. Vincents University Hospital , Dublin , Ireland.
[Ti] Título:Recall of structured radiology reports is significantly superior to that of unstructured reports.
[So] Source:Br J Radiol;91(1083):20170670, 2018 Feb.
[Is] ISSN:1748-880X
[Cp] País de publicação:England
[La] Idioma:eng
[Ab] Resumo:OBJECTIVE: To measure recall of structured compared with unstructured radiology reports. METHODS: Institutional review board approval was obtained. Four hypothetical radiology reports, two structured and two unstructured reports, were created for the purposes of this study by an experienced consultant radiologist. The reports, each followed immediately by a multiple-choice questionnaire listing possible diagnoses from the report, were distributed to the members of two national physician associations using a web-based survey tool. Based on the number of correct responses, correct critical findings and incorrect responses, rates per number of potential diagnoses were calculated for each individual and averaged. The paired sign test compared results between structured and unstructured reports. RESULTS: 148 respondents completed the survey, 126 (85.1%) of whom were physicians. The mean percentage of incorrect diagnoses was 4.5% for structured reports compared with 16.7% for unstructured reports (p < 0.001). The average rate of critical diagnosis recall was 82.7% for structured reports and 65.1% for unstructured reports (p < 0.001). The average percentage of all diagnoses detected for structured compared with unstructured reports was 64.3 and 59.0%, respectively (p = 0.007). CONCLUSION: Recall of structured radiology reports is significantly superior to recall of unstructured reports immediately after reading the report. Advances in knowledge: A structured radiology report format can positively impact the referring clinician's ability to recall the critical findings with statistically significance.
[Mh] Termos MeSH primário: Erros de Diagnóstico/estatística & dados numéricos
Documentação/normas
Controle de Formulários e Registros
[Mh] Termos MeSH secundário: Adulto
Competência Clínica
Feminino
Seres Humanos
Masculino
Sistemas de Informação em Radiologia
Inquéritos e Questionários
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1802
[Cu] Atualização por classe:180226
[Lr] Data última revisão:
180226
[Sb] Subgrupo de revista:AIM; IM
[Da] Data de entrada para processamento:171201
[St] Status:MEDLINE
[do] DOI:10.1259/bjr.20170670


  4 / 7729 MEDLINE  
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[PMID]:28974521
[Au] Autor:Sandau KE; Funk M; Auerbach A; Barsness GW; Blum K; Cvach M; Lampert R; May JL; McDaniel GM; Perez MV; Sendelbach S; Sommargren CE; Wang PJ; American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Cardiovascular Disease in the Young
[Ti] Título:Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association.
[So] Source:Circulation;136(19):e273-e344, 2017 Nov 07.
[Is] ISSN:1524-4539
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:BACKGROUND AND PURPOSE: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electro cardiographic monitoring of hospitalized patients. Since the original practice standards were published in 2004, new issues have emerged that need to be addressed: overuse of arrhythmia monitoring among a variety of patient populations, appropriate use of ischemia and QT-interval monitoring among select populations, alarm management, and documentation in electronic health records. METHODS: Authors were commissioned by the American Heart Association and included experts from general cardiology, electrophysiology (adult and pediatric), and interventional cardiology, as well as a hospitalist and experts in alarm management. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Authors were assigned topics relevant to their areas of expertise, reviewed the literature with an emphasis on publications since the prior practice standards, and drafted recommendations on indications and duration for electrocardiographic monitoring in accordance with the American Heart Association Level of Evidence grading algorithm that was in place at the time of commissioning. RESULTS: The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice Standards; and (5) Call for Research. CONCLUSIONS: Many of the recommendations are based on limited data, so authors conclude with specific questions for further research.
[Mh] Termos MeSH primário: American Heart Association
Arritmias Cardíacas/diagnóstico
Serviço Hospitalar de Cardiologia/normas
Eletrocardiografia/normas
Hospitalização
[Mh] Termos MeSH secundário: Arritmias Cardíacas/fisiopatologia
Arritmias Cardíacas/terapia
Alarmes Clínicos/normas
Consenso
Documentação/normas
Eletrocardiografia Ambulatorial/normas
Registros Eletrônicos de Saúde/normas
Medicina Baseada em Evidências/normas
Teste de Esforço/normas
Controle de Formulários e Registros/normas
Seres Humanos
Valor Preditivo dos Testes
Prognóstico
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE; PRACTICE GUIDELINE; REVIEW
[Em] Mês de entrada:1711
[Cu] Atualização por classe:171113
[Lr] Data última revisão:
171113
[Sb] Subgrupo de revista:AIM; IM
[Da] Data de entrada para processamento:171005
[St] Status:MEDLINE
[do] DOI:10.1161/CIR.0000000000000527


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[PMID]:28668097
[Au] Autor:Sanderson S
[Ti] Título:Medico-Legal Considerations in Providing Emergency Dental Care in Practice.
[So] Source:Prim Dent J;6(2):20-25, 2017 May 01.
[Is] ISSN:2050-1684
[Cp] País de publicação:England
[La] Idioma:eng
[Ab] Resumo: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.
[Mh] Termos MeSH primário: Assistência Odontológica/organização & administração
Tratamento de Emergência/métodos
Administração da Prática Odontológica/organização & administração
[Mh] Termos MeSH secundário: Comunicação
Assistência Odontológica/legislação & jurisprudência
Controle de Formulários e Registros/legislação & jurisprudência
Controle de Formulários e Registros/organização & administração
Seres Humanos
Consentimento Livre e Esclarecido/legislação & jurisprudência
Administração da Prática Odontológica/legislação & jurisprudência
Gestão de Riscos/legislação & jurisprudência
Gestão de Riscos/organização & administração
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1708
[Cu] Atualização por classe:170821
[Lr] Data última revisão:
170821
[Sb] Subgrupo de revista:D
[Da] Data de entrada para processamento:170703
[St] Status:MEDLINE
[do] DOI:10.1308/205016817821281783


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[PMID]:28648135
[Au] Autor:Rabbetts L
[Ad] Endereço:Nursing Lecturer, University of South Australia, Australia.
[Ti] Título:Peer mentoring supports the learning needs of nurses providing palliative care in a rural acute care setting.
[So] Source:Int J Palliat Nurs;23(6):280-286, 2017 Jun 02.
[Is] ISSN:1357-6321
[Cp] País de publicação:England
[La] Idioma:eng
[Ab] Resumo:BACKGROUND: A specific set of assessment scales can underpin the management of distressing symptoms of patients requiring palliative care. A research assistant supported nurses working in a rural hospital setting during the introduction of these scales. AIM: A secondary analysis was conducted to further explore the qualitative data of a previously reported mixed-method study. In particular, the experiences of nurses working alongside a research assistant in the facilitation of using a new assessment form. METHOD: Purposeful sampling was employed: participating nurses were invited to attend one of three focus group meetings. FINDINGS: Data analysis revealed three main themes: a contact person, coach/mentor and extra help initiatives. Three to four subthemes corresponded with each main theme. CONCLUSION: Findings suggest nurses benefit from having someone to assist in learning about new documentation. Nurses respond positively to mentorship and practical guidance when integrating a new assessment form into routine evidence-based practice.
[Mh] Termos MeSH primário: Enfermagem de Cuidados Paliativos na Terminalidade da Vida
Tutoria
Avaliação em Enfermagem
Grupo Associado
Serviços de Saúde Rural
[Mh] Termos MeSH secundário: Austrália
Controle de Formulários e Registros
Seres Humanos
Determinação de Necessidades de Cuidados de Saúde
Pesquisa em Enfermagem
Pesquisadores
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1708
[Cu] Atualização por classe:170829
[Lr] Data última revisão:
170829
[Sb] Subgrupo de revista:N
[Da] Data de entrada para processamento:170627
[St] Status:MEDLINE
[do] DOI:10.12968/ijpn.2017.23.6.280


  7 / 7729 MEDLINE  
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[PMID]:28497945
[Au] Autor:Occupational Safety and Health Administration (OSHA), Labor
[Ti] Título:Clarification of Employer's Continuing Obligation To Make and Maintain an Accurate Record of Each Recordable Injury and Illness. Final rule.
[So] Source:Fed Regist;82(84):20548-9, 2017 May 03.
[Is] ISSN:0097-6326
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:Under the Congressional Review Act, Congress has passed, and the President has signed, Public Law 115-21, a resolution of disapproval of OSHA's final rule titled, "Clarification of Employer's Continuing Obligation to Make and Maintain an Accurate Record of each Recordable Injury and Illness." OSHA published the rule, which contained various amendments to OSHA's recordkeeping regulations, on December 19, 2016. The amendments became effective on January 18, 2017. Because Public Law 115-21 invalidates the amendments to OSHA's recordkeeping regulations contained in the rule promulgated on December 19, 2016, OSHA is hereby removing those amendments from the Code of Federal Regulations.
[Mh] Termos MeSH primário: Controle de Formulários e Registros/legislação & jurisprudência
Doenças Profissionais
Saúde do Trabalhador/legislação & jurisprudência
Traumatismos Ocupacionais
Registros como Assunto/legislação & jurisprudência
United States Occupational Safety and Health Administration/legislação & jurisprudência
[Mh] Termos MeSH secundário: Seres Humanos
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1705
[Cu] Atualização por classe:170525
[Lr] Data última revisão:
170525
[Sb] Subgrupo de revista:T
[Da] Data de entrada para processamento:170513
[St] Status:MEDLINE


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[PMID]:28333719
[Au] Autor:Drobny SD
[Ad] Endereço:Stephanie D. Drobny is the northern Colorado senior manager for outpatient oncology and infusion at Banner Health. Contact author: stephanie.drobny@gmail.com. The author has disclosed no potential conflicts of interest, financial or otherwise.
[Ti] Título:Making Patients Partners in Real-Time Electronic Charting.
[So] Source:Am J Nurs;117(4):11, 2017 Apr.
[Is] ISSN:1538-7488
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:This form of team charting builds trust with patients and improves health literacy.
[Mh] Termos MeSH primário: Registros Eletrônicos de Saúde/normas
Alfabetização em Saúde/organização & administração
Registros de Enfermagem/normas
Educação de Pacientes como Assunto/métodos
Participação do Paciente
[Mh] Termos MeSH secundário: Controle de Formulários e Registros
Seres Humanos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1704
[Cu] Atualização por classe:170410
[Lr] Data última revisão:
170410
[Sb] Subgrupo de revista:AIM; IM; N
[Da] Data de entrada para processamento:170324
[St] Status:MEDLINE
[do] DOI:10.1097/01.NAJ.0000515210.54473.ce


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[PMID]:28209392
[Au] Autor:McQuown CM; Frey JA; Amireh A; Chaudhary A
[Ad] Endereço:Summa Akron City Hospital, Department of Emergency Medicine, 525 East Market St, Akron, OH 44304, United States; Northeast Ohio Medical University, 4209 Ohio 44, Rootstown, OH 44272, United States. Electronic address: mcmcquown@yahoo.com.
[Ti] Título:Transfer of DNR orders to the ED from extended care facilities.
[So] Source:Am J Emerg Med;35(7):983-985, 2017 Jul.
[Is] ISSN:1532-8171
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo: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.
[Mh] Termos MeSH primário: Diretivas Antecipadas
Estado Terminal
Serviços Médicos de Emergência/organização & administração
Controle de Formulários e Registros/organização & administração
Serviços de Saúde para Idosos
Registros Médicos/estatística & dados numéricos
Instituições de Cuidados Especializados de Enfermagem
[Mh] Termos MeSH secundário: Idoso
Idoso de 80 Anos ou mais
Serviço Hospitalar de Emergência
Feminino
Controle de Formulários e Registros/normas
Seres Humanos
Tempo de Internação
Masculino
Meia-Idade
Ohio
Avaliação de Resultados (Cuidados de Saúde)
Defesa do Paciente
Médicos
Estudos Prospectivos
Ordens quanto à Conduta (Ética Médica)
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1710
[Cu] Atualização por classe:171004
[Lr] Data última revisão:
171004
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:170218
[St] Status:MEDLINE


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[PMID]:28207594
[Au] Autor:Weintraub AY; Deutsch ES; Hales RL; Buchanan NA; Rock WL; Rehman MA
[Ad] Endereço:From the Departments of *Anesthesiology and Critical Care Medicine; ‡Center for Simulation, Advanced Education and Innovation; §Biomedical Engineering, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and †ECRI Institute, Plymouth Meeting, Pennsylvania.
[Ti] Título:Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report.
[So] Source:Anesth Analg;124(6):1815-1819, 2017 Jun.
[Is] ISSN:1526-7598
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.
[Mh] Termos MeSH primário: Anestesiologistas/educação
Instrução por Computador/métodos
Educação Médica Continuada/métodos
Registros Eletrônicos de Saúde
Gestão da Informação em Saúde
Treinamento com Simulação de Alta Fidelidade/métodos
Manequins
[Mh] Termos MeSH secundário: Anestesiologistas/psicologia
Atitude do Pessoal de Saúde
Competência Clínica
Documentação
Estudos de Viabilidade
Controle de Formulários e Registros
Conhecimentos, Atitudes e Prática em Saúde
Seres Humanos
Análise e Desempenho de Tarefas
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1708
[Cu] Atualização por classe:170814
[Lr] Data última revisão:
170814
[Sb] Subgrupo de revista:AIM; IM
[Da] Data de entrada para processamento:170217
[St] Status:MEDLINE
[do] DOI:10.1213/ANE.0000000000001775



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