Illegible handwriting in medical records

Enhancing WHO Prescription writing guideline adherence through an educational intervention - a quality improvement study of Azad Jammu and Kashmir

BACKGROUND

Prescription writing is an important component of healthcare delivery and can directly influence patient safety and treatment outcomes. Prescription errors are common in developing countries because of the lack of national guidelines. This two-cycle clinical audit assessed the impact of educational interventions on improving prescription writing practices.

METHODS

A cross-sectional prospective clinical audit was conducted in the Out Patients Department (OPD) of the District Head Quarters (DHQ) Hospital in Bhimber, Azad Jammu, and Kashmir. A total of 100 randomly selected prescriptions were reviewed for each cycle from July to August 2023. We recorded compliance with WHO guidelines for prescription writing before and after the educational intervention. Microsoft Excel and SPSS version 25.0 were used for statistical analysis. Categorical variables were analyzed using frequencies and percentages.

RESULTS

An improvement in compliance was observed during the 2nd audit cycle, after the educational intervention. The greatest improvement was observed in documenting the allergic status of patients (62%) and the direction of drug administration (40%). We also observed improvements in the treatment duration (>10%), patient weight, physician registration number, diagnosis, and follow-up advice. The legibility of prescriptions also improved during the 2nd audit cycle.

CONCLUSION

This study shows that integrating an educational intervention into a clinical audit can improve prescription writing practices and ultimately result in better quality of care for patients.

Digital disparities among healthcare workers in typing speed between generations, genders, and medical specialties: cross sectional study

OBJECTIVE

To investigate the typing skills of healthcare professionals.

DESIGN

Cross sectional study.

SETTING

Two large tertiary medical centres in Amsterdam, the Netherlands.

PARTICIPANTS

2690 hospital employees working in patient care, research, or medical education.

MAIN OUTCOME MEASURES

Participants completed a custom built, web based, Santa themed, typing test in 60 seconds and filled out an associated questionnaire. The primary outcome was corrected typing speed, defined as crude typing speed (words per minute) multiplied by accuracy (correct characters as a percentage of total characters in the final transcribed text). Feelings towards administrative tasks scored on the Visual Analogue Scale to Weigh Respondents' Internalised Typing Enjoyment (VAS-WRITE), in which 0 represents the most negative and 100 the most positive feelings towards administration, were also recorded.

RESULTS

Between 18 and 21 May 2021, a representative cohort of 2690 study participants was recruited (1942 (72.2%) were younger than 40 years; 2065 (76.8%) were women). Respondents' mean typing speed was 60.1 corrected words per minute (standard deviation 20.8; range 8.0-136.6) with substantial differences between professions and specialties, in which physicians in internal medicine were the fastest among the medical professionals. Typing speed decreased significantly with every age decade (rho -0.51, P<0.001), and people with a history of completing a typing course were more than 20% faster than those who had not (mean difference 12.1 words (standard error 0.8), (95% confidence interval 10.6 to 13.6), P<0.001). The corrected typing speed did not differ between genders (0.5 (0.9) words, (-1.4 to 2.4), P=0.61). Women were less negative towards administration than were men (mean difference VAS-WRITE score 7.68 (standard error 1.17), (95% confidence interval 5.33 to 10.03), P<0.001). Of all professional groups, medical staff reported the most negative feelings towards administration (mean VAS-WRITE score of 33.5 (standard deviation 22.9)).

CONCLUSIONS

Important differences were reported in typing proficiency between age groups, professions, and medical specialties. Specific groups are at a disadvantage in an increasingly digitalised healthcare system, and these data could inform the implementation of training modules and alternative methods of data entry to level the playing field.

Impact of Illegible Prescriptions on Dispensing Practice: A Pilot Study of South African Pharmacy Personnel

Illegible prescriptions are an illegal, frequent, and longstanding problem for pharmacy personnel engaged in dispensing. These contribute to patient safety issues and negatively impact safe dispensing in pharmaceutical delivery. To date, little is documented on measures taken to assess the negative impact posed by illegible prescriptions on South African pharmacy dispensing personnel. Therefore, this pilot study was performed to evaluate the ability of pharmacy personnel to read and interpret illegible prescriptions correctly; and to report on their perceived challenges, views and concerns when presented with an illegible prescription to dispense. A cross-sectional, three-tiered self-administered survey was conducted among pharmacy personnel. A total of 885 measurements were recorded. The ability to read an illegible prescription is not an indicator of competency, as all (100%) participants (novice and experienced) made errors and experienced difficulty evaluating and deciphering the illegible prescription. The medication names and dosages were correctly identified by only 20% and 18% of all participants. The use of digital prescriptions was indicated by 70% of the participants as a probable solution to the problem. Overall, improving the quality of written prescriptions and instructions can potentially assist dispensing pharmacy personnel in reducing illegible prescription-related patient safety issues and dispensing errors.

Sijilli: A Scalable Model of Cloud-Based Electronic Health Records for Migrating Populations in Low-Resource Settings

The world is witnessing an alarming rate of displacement and migration, with more than 70.8 million forcibly displaced individuals, including 26 million refugees. These populations are known to have increased vulnerability and susceptibility to mental and physical health problems due to the migration journey. Access of these individuals to health services, whether during their trajectory of displacement or in refugee-hosting countries, remains limited and challenging due to multiple factors, including language and cultural barriers and unavailability of the refugees' health records. Cloud-based electronic health records (EHRs) are considered among the top five health technologies integrated in humanitarian crisis preparedness and response during times of conflict. This viewpoint describes the design and implementation of a scalable and innovative cloud-based EHR named Sijilli, which targets refugees in low-resource settings. This paper discusses this solution compared with other similar practices, shedding light on its potential for scalability.

[Success, satisfaction and improvement of informed consents for computed tomography : A survey among patients and physicians]

Hintergrund

Die Aufklärung eines Patienten vor einer Computertomographie (CT) spielt sowohl für die aufklärenden Ärzte als auch für die Patienten eine entscheidende Rolle. Ein persönliches Aufklärungsgespräch über die Durchführung, Risiken und mögliche Alternativen ist vor einer CT-Untersuchung verpflichtend.

Methode

Durchgeführt wurde eine Befragung zur Patientenzufriedenheit hinsichtlich der Dauer und den Inhalten einer CT-Aufklärung. Befragt wurden hierüber auch aufklärende Ärzte. Ein weiterer Teil der Befragung beschäftigte sich mit der Akzeptanz technischer Hilfsmittel, wie z. B. Informationsvideos oder Tablets/PCs.

Ergebnis

Insgesamt 512 Patienten und 106 Ärzte beteiligten sich an der Befragung. Die Dauer des Aufklärungsgesprächs gaben die Patienten mit durchschnittlich 4,08 min und die Ärzte mit 4,7 min an. Am ausführlichsten klärten die Ärzte über die Nebenwirkungen von Kontrastmitteln auf. Über mögliche Alternativen und die Notwendigkeit der Untersuchung wurde weniger aufgeklärt. Korrelierend erinnerten sich rund 92 % aller Patienten nicht an eine Information über alternative Untersuchungsmöglichkeiten. 88,7 % der Patienten und 95,3 % der ärztlichen Teilnehmer befürworteten die Aufklärung mithilfe von interaktiven Videos und Animationen und 74 % der Patienten sowie 98,8 % der Ärzte die Beantwortung der Fragen zum Gesundheitszustand am Tablet/PC.

Schlussfolgerung

Die Dauer einer CT-Aufklärung wurde von den Patienten etwas kürzer eingeschätzt, wobei sich die Patienten teilweise nur schlecht an die Aufklärungsinhalte erinnerten. Die Akzeptanz gegenüber technischen Neuerungen war bei den Teilnehmern sehr hoch. Durch den Einsatz von Informationsvideos und Tablets/PCs könnte der Aufklärungserfolg erhöht werden.

[Analysis of documented informed consent forms for computed tomography : Completeness and data quality in four clinics]

BACKGROUND

Before performing a medical procedure, such as a computed tomography, an obligatory informed consent of the patient and its detailed documentation is necessary.

METHODS

A total of 1424 informed consent forms for contrast-enhanced computed tomography from four clinics with different healthcare levels were analyzed. Informed consent forms were evaluated related to completeness, legibility and quality.

RESULTS

In all, 1110 (77.9%) informed consent forms were sufficiently completed, 267 patients (18.8%) answered the form incompletely and 47 patients (3.3%) returned it without answering a question. Handwritten comments were found in 1391 (97.7%) cases. Thereof, 1329 (93.3%) were graded as detailed comments and 62 (4.4%) as less detailed comments. These comments were well legible in 675 (47.4%) cases, 558 (39.2%) informed consents showed limited legibility and in 158 (11.1%) more than 50% of the comments were unreadable. Signatures were complete in 1374 (96.5%) informed consent forms.

CONCLUSION

The results show a better quality and documentation of informed consent forms for computed tomography obtained by radiology residents compared to radiological specialists. Compared to the radiologists, the non-radiologists performed significantly worse. The establishment of videos and use of digital informed consent forms could provide a possible solution.

Hospital mortality statistics in Tanzania: availability, accessibility, and quality 2006-2015

Background

Accurate and reliable hospital information on the pattern and causes of death is important to monitor and evaluate the effectiveness of health policies and programs. The objective of this study was to assess the availability, accessibility, and quality of hospital mortality data in Tanzania.

Methods

This cross-sectional study involved selected hospitals of Tanzania and was carried out from July to October 2016. Review of hospital death registers and forms was carried out to cover a period of 10 years (2006–2015). Interviews with hospital staff were conducted to seek information as regards to tools used to record mortality data, staff involved in recording and availability of data storage and archiving facilities.

Results

A total of 247,976 death records were reviewed. The death register was the most (92.3%) common source of mortality data. Other sources included the International Classification of Diseases (ICD) report forms, Inpatient registers, and hospital administrative reports. Death registers were available throughout the 10-year period while ICD-10 forms were available for the period of 2013–2015. In the years between 2006 and 2010 and 2011–2015, the use of death register increased from 82 to 94.9%. Three years after the introduction of ICD-10 procedure, the forms were available and used in 28% (11/39) hospitals. The level of acceptable data increased from 69% in 2006 to 97% in 2015. Inconsistency in the language used, use of non-standard nomenclature for causes of death, use of abbreviations, poorly and unreadable handwriting, and missing variables were common data quality challenges. About 6.3% (n = 15,719) of the records had no patient age, 3.5% (n = 8790) had no cause of death and ~ 1% had no sex indicated. The frequency of missing sex variable was most common among under-5 children. Data storage and archiving in most hospitals was generally poor. Registers and forms were stored in several different locations, making accessibility difficult.

Conclusion

Overall, this study demonstrates gaps in hospital mortality data availability, accessibility, and quality, and highlights the need for capacity strengthening in data management and periodic record reviews. Policy guidelines on the data management including archiving are necessary to improve data.

Adherence to UK national guidance for discharge information: an audit in primary care

AIMS

Poor communication of clinical information between healthcare settings is associated with patient harm. In 2008, the UK National Prescribing Centre (NPC) issued guidance regarding the minimum information to be communicated upon hospital discharge. This study evaluates the extent of adherence to this guidance and identifies predictors of adherence.

METHODS

This was an audit of discharge summaries received by medical practices in one UK primary care trust of patients hospitalized for 24 h or longer. Each discharge summary was scored against the applicable NPC criteria which were organized into: 'patient, admission and discharge', 'medicine' and 'therapy change' information.

RESULTS

Of 3444 discharge summaries audited, 2421 (70.3%) were from two teaching hospitals and 906 (26.3%) from three district hospitals. Unplanned admissions accounted for 2168 (63.0%) of the audit sample and 74.6% (2570) of discharge summaries were electronic. Mean (95% CI) adherence to the total NPC minimum dataset was 71.7% [70.2, 73.2]. Adherence to patient, admission and discharge information was 77.3% (95% CI 77.0, 77.7), 67.2% (95% CI 66.3, 68.2) for medicine information and 48.9% (95% CI 47.5, 50.3) for therapy change information. Allergy status, co-morbidities, medication history and rationale for therapy change were the most frequent omissions. Predictors of adherence included quality of the discharge template, electronic discharge summaries and smaller numbers of prescribed medicines.

CONCLUSIONS

Despite clear guidance regarding the content of discharge information, omissions are frequent. Adherence to the NPC minimum dataset might be improved by using comprehensive electronic discharge templates and implementation of effective medicines reconciliation at both sides of the health interface.

SEND: a system for electronic notification and documentation of vital sign observations

BACKGROUND

Recognising the limitations of a paper-based approach to documenting vital sign observations and responding to national clinical guidelines, we have explored the use of an electronic solution that could improve the quality and safety of patient care. We have developed a system for recording vital sign observations at the bedside, automatically calculating an Early Warning Score, and saving data such that it is accessible to all relevant clinicians within a hospital trust. We have studied current clinical practice of using paper observation charts, and attempted to streamline the process. We describe our user-focussed design process, and present the key design decisions prior to describing the system in greater detail.

RESULTS

The system has been deployed in three pilot clinical areas over a period of 9 months. During this time, vital sign observations were recorded electronically using our system. Analysis of the number of observations recorded (21,316 observations) and the number of active users (111 users) confirmed that the system is being used for routine clinical observations. Feedback from clinical end-users was collected to assess user acceptance of the system. This resulted in a System Usability Scale score of 77.8, indicating high user acceptability.

CONCLUSIONS

Our system has been successfully piloted, and is in the process of full implementation throughout adult inpatient clinical areas in the Oxford University Hospitals. Whilst our results demonstrate qualitative acceptance of the system, its quantitative effect on clinical care is yet to be evaluated.

Lung sounds: how doctors draw crackles and wheeze

BACKGROUND

The content of medical records is a potential source of miscommunication between clinicians. Doctors' written entries have been criticised for their illegibility and ambiguity, but no studies have examined doctors' drawings that are commonly used for recording auscultation findings.

OBJECTIVE

To compare doctors' drawings of auscultation findings, based on identical clinical information.

METHODS

Doctors at the Royal London Hospital and a group of London based general practitioners (GPs) documented a respiratory examination with a drawing of the auscultation findings of bilateral mid and lower zone wheeze and right lower zone crackles. The graphical properties of each drawing were examined and the use of written captions and labels recorded. Drawings were classified into styles according to the use of symbols (defined as discrete characters or icons) and shading (cross-hatching, speckling or darkening) to depict the auscultation findings. The study was conducted between September and November 2011.

RESULTS

Sixty-nine hospital doctors and 13 GPs participated. Ten drawing styles were identified from 78 completed drawings. Ten distinct symbols and a range of shading techniques were used. The most frequent style (21% of drawings) combined 'X' symbols representing crackles with musical notes for wheeze. There was inconsistency of representation across the drawings. Forty-seven (60%) drawings used an 'X' symbol exclusively to represent crackles, but six (8%) used 'X' only to represent wheeze, and 10 (13%) used 'X' to represent both findings. 91% of participants included captions or labels with their drawing.

CONCLUSIONS

There was wide variation in doctors' drawings of identical auscultation findings, and inconsistency in the meaning of symbols both between and within drawings. Doctors risk incorrectly interpreting each other's drawings when they are not effectively labelled. We recommend doctors consider using a written description instead, or draw different findings with distinct symbols or shading, labelling all findings clearly.

Relevance of the expression "obs stable" in nursing observations: retrospective study

OBJECTIVE

To ascertain whether use of the term "obs stable" with respect to the nursing observations is so liberal as to render it meaningless.

DESIGN

Retrospective study.

SETTING

Three teaching hospitals in London, United Kingdom.

METHODS

We searched progress notes for the current admission of 46 inpatients for entries containing the phrases "obs stable" and "observations stable," and reviewed the nursing observations recorded during the 24 hour period preceding each entry containing at least one phrase. We calculated the frequency of abnormalities and of persistent abnormalities (defined as occurring in every observation) observed during these 24 hour periods, and the range of observation values over a 24 hour period if at least two observations had been recorded.

RESULTS

We found at least one entry in 36 (78%) progress notes (95% confidence interval 66% to 90%). Observations in the 24 hours preceding an entry included at least one abnormality for 113 (71%) of 159 cases and at least one persistent abnormality for 31 (19%). The most frequently occurring abnormalities were tachypnoea (respiratory rate ≥20 breaths/min) and hypotension (systolic blood pressure <100 mm Hg). An abnormality occurred in the observations immediately preceding an entry in 42% of cases. Mean ranges of observations over 24 hours were within the limits of normal diurnal variation, although we found that some instances of greater than normal variability were described as "stable."

CONCLUSIONS

The expression "obs stable" does not reliably indicate normal observations or variations in observations within physiological limits. Doctors should avoid using the expression altogether or clarify it with further information.

The seamless transition from student to intern: from theory to practice

Many publications have highlighted a lack of practical competencies in recently qualified interns. Consultation between the University of Queensland and the Medical Education Unit at Redcliffe Hospital identified key areas where intervention could lead to greater work readiness, and the development of a complementary programme of practical workshops to remedy those deficiencies. A variety of content experts introduced the Graduate Medical Course 3 and 4 students to a range of practical skills during a dedicated lunch time one hour workshop each week over a period of 30 weeks. Several sessions were audited by the trainers though the majority of sessions used self-evaluation by the participants. There was an overall self-reported increase in the ability to perform the tasks from 25% before the session to 90% afterwards. Seven of the participants are returning to the hospital as interns, and a follow-up survey will be performed to judge the usefulness of the programme.

Benefits and drawbacks of electronic health record systems

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 that was signed into law as part of the "stimulus package" represents the largest US initiative to date that is designed to encourage widespread use of electronic health records (EHRs). In light of the changes anticipated from this policy initiative, the purpose of this paper is to review and summarize the literature on the benefits and drawbacks of EHR systems. Much of the literature has focused on key EHR functionalities, including clinical decision support systems, computerized order entry systems, and health information exchange. Our paper describes the potential benefits of EHRs that include clinical outcomes (eg, improved quality, reduced medical errors), organizational outcomes (eg, financial and operational benefits), and societal outcomes (eg, improved ability to conduct research, improved population health, reduced costs). Despite these benefits, studies in the literature highlight drawbacks associated with EHRs, which include the high upfront acquisition costs, ongoing maintenance costs, and disruptions to workflows that contribute to temporary losses in productivity that are the result of learning a new system. Moreover, EHRs are associated with potential perceived privacy concerns among patients, which are further addressed legislatively in the HITECH Act. Overall, experts and policymakers believe that significant benefits to patients and society can be realized when EHRs are widely adopted and used in a "meaningful" way.

Does an education intervention improve physician signature legibility? Pilot study of a prospective chart review

Illegible physician signatures in patient records can lead to inaccurate documentation, improper billing, and potential legal issues. Many studies in the current literature address legibility of prescriptions and medication orders; however, few focus on legibility of physicians' signatures. The purpose of the present quality improvement survey was to evaluate physician signature legibility on patient charts at the University of Mississippi Medical Center's Adult Internal Medicine Clinic. At the time of the study, the clinic was known as the University of Mississippi Medical Center (UMMC) Adult Internal Medicine Clinic. Effective July 1, 2009, UMMC entered into a collaboration with Jackson-Hinds Comprehensive Health Center (JHCHC), a federally qualified health center. The clinic is now known as the Federally Qualified Health Center at the Jackson Medical Mall. In this pilot study, we examined clinic notes and billing sheets for legible physician signatures over a three-month period. Midway through the study, an intervention group was given name stamps and a standardized discussion on the importance of signature legibility and proper name stamp usage. Legibility of resident signatures in the intervention group increased from 26 percent to 60 percent. Legibility of attending signatures in the intervention group increased from 1.4 percent to 86 percent. Results suggest the significant impact of resident education on changing practice behavior.

Prescription writing practices in a rural tertiary care hospital in Western Maharashtra, India

BACKGROUND

Prescription is a written order from physician to pharmacist which contains name of drug, its dose and its method of dispensing and advice over consuming it. The frequency of drug prescription errors is high. Prescribing error contributes significantly towards adverse drug events. The present study was undertaken to understand the current prescription writing practices and to detect the common errors in them at a tertiary health care centre situated in a rural area of Western Maharashtra, India.

METHOD

A cross sectional study was conducted at a tertiary level hospital located at a rural area of Maharashtra state, India during October 2009-March 2010. 499 prescriptions coming to medical store during period of one month were considered for data analysis. Important information regarding the patient, doctor, drug and the general description of the prescription were obtained.

RESULTS

All the prescriptions were on the hospital pad. A significant number of the prescriptions (n=88, 17.6%) were written in illegible handwriting and not easily readable. The name, age and sex of the patient were mentioned is majority of the prescriptions. All the prescriptions (100%) failed to demonstrate the presence of address, height and weight of the patient. Only the brand name of the drugs was mentioned in all the prescriptions with none of them having the generic name. The strength, quantity and route of administration of the drug were found on 73.1%, 65.3% and 75.2% prescriptions.

CONCLUSION

There are widespread errors in prescription writing by the doctors. Educational intervention programs and use of computer can substantially contribute in the lowering of such errors. A short course on prescription writing before the medical student enters the clinical field and strict monitoring by the administrative authorities may also help alleviate the problem.

Auditing psychiatric out-patient records

PURPOSE

Up-to-date patient records are essential for safe and professional practice. They are an intrinsic component for providing adequate care and ensuring appropriate and systematic treatment 2009 plans. Furthermore, accurate and contemporaneous notes are essential for achieving professional standards from a medico-legal perspective. The study's main aim was to investigate current record-keeping practices by looking at whether out-patient communication pathways to general practitioners, from letter dictation to insertion in the chart, were being satisfied.

DESIGN/METHODOLOGY/APPROACH

From current out-patient attendees over six months, 100 charts were chosen randomly, and reviewed. A pro-forma was used to collect data and this information was also checked against electronic records.

FINDINGS

Of the charts reviewed, 15 per cent had no letter. If one considers that one-month is an acceptable time for letters to be inserted into the chart, then only 11 per cent satisfied this condition. Electronic data were also missing.

RESEARCH LIMITATIONS/IMPLICATIONS

It is impossible to discern whether letters to GPs were dictated by the out-patient doctor for each patient reviewed. Another limitation was that some multidisciplinary hospital teams have different out-patient note-keeping procedures, which makes some findings difficult to interpret.

PRACTICAL IMPLICATIONS

The review drew attention to current record-keeping discrepancies, highlighting the need for medical record-keeping procedures and polices to be put in place. Also brought to light was the importance of providing a workforce sufficient to meet the out-patient team's administrative needs. An extended audit of other medical record-keeping aspects should be carried out to determine whether problems occur in other areas.

ORIGINALITY/VALUE

The study highlights the importance of establishing agreed policies and procedures for out-patient record keeping and the need to have a checking mechanism to identify system weaknesses.

The health information system security threat lifecycle: an informatics theory

PURPOSE

This manuscript describes the health information system security threat lifecycle (HISSTL) theory. The theory is grounded in case study data analyzing clinicians' health information system (HIS) privacy and security (P&S) experiences in the practice context.

METHODS

The 'questerview' technique was applied to this study of 26 clinicians situated in 3 large Australian (across Victoria) teaching hospitals. Questerviews rely on data collection that apply standardized questions and questionnaires during recorded interviews. Analysis (using Nvivo) involved the iterative scrutiny of interview transcripts to identify emergent themes.

RESULTS

Issues including poor training, ambiguous legal frameworks containing punitive threats, productivity challenges, usability errors and the limitations of the natural hospital environment emerged from empirical data about the clinicians' HIS P&S practices. The natural hospital environment is defined by the permanence of electronic HISs (e-HISs), shared workspaces, outdated HIT infrastructure, constant interruption, a P&S regulatory environment that is not conducive to optimal training outcomes and budgetary constraints. The evidence also indicated the obtrusiveness, timeliness, and reliability of P&S implementations for clinical work affected participant attitudes to, and use of, e-HISs.

CONCLUSION

The HISSTL emerged from the analysis of study evidence. The theory embodies elements such as the fiscal, regulatory and natural hospital environments which impede P&S implementations in practice settings. These elements conflict with improved patient care outcomes. Efforts by clinicians to avoid conflict and emphasize patient care above P&S tended to manifest as security breaches. These breaches entrench factors beyond clinician control and perpetuate those within clinician control. Security breaches of health information can progress through the HISSTL. Some preliminary suggestions for addressing these issues are proposed.

STUDY LIMITATIONS

Legislative frameworks that are not related to direct patient care were excluded from this study. Other limitations included an exclusive focus on patient care tasks post-admission and pre-discharge from public hospital wards. Finally, the number of cases was limited by the number of participants who volunteered to participate in the study. It is reasonable to assume these participants were more interested in the P&S of patient care work than their counterparts, though the study was not intended to provide quantitative or statistical data. Nonetheless, additional case studies would strengthen the HISSTL theory if confirmatory, practice-based evidence were found.

Impact of computerized information systems on workload in operating room and intensive care unit

The number of operating rooms and intensive care departments equipped with a clinical information system (CIS) is rapidly expanding. Amongst the putative advantages of such an installation, reduction in workload for the clinician is one of the most appealing. The scarce studies looking at workload variations associated with the implementation of a CIS, only focus on direct workload discarding indirect changes in workload. Descriptions of the various methods to quantify workload are provided. The hypothesis that a third generation CIS can reduce documentation time for ICU nurses and increase time they spend on patient care, is supported by recent literature. Though it seems obvious to extrapolate these advantages of a CIS to the anesthesiology department or physicians in the intensive care, studies examining this assumption are scarce.

What they fill in today, may not be useful tomorrow: lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

Background

The medical record is used to document patient's medical history, illnesses and treatment procedures. The information inside is useful when all needed information is documented properly. Medical care providers in Iran have complained of low quality of Medical Records. This study was designed to evaluate the quality of the Medical Records at the university hospital in Tabriz, Iran.

Methods

In order to get a background of the quality of documentation, 300 Medical Records were randomly selected among all hospitalized patient during September 23, 2003 and September 22, 2004. Documentation of all records was evaluated using checklists. Then, in order to combine objective data with subjective, 10 physicians and 10 nurses who were involved in documentation of Medical Records were randomly selected and interviewed using two semi structured guidelines.

Results

Almost all 300 Medical Records had problems in terms of quality of documentation. There was no record in which all information was documented correctly and compatible with the official format in Medical Records provided by Ministry of Health and Medical Education. Interviewees believed that poor handwriting, missing of sheets and imperfect documentation are major problems of the Paper-based Medical Records, and the main reason was believed to be high workload of both physicians and nurses.

Conclusion

The Medical Records are expected to be complete and accurate. Our study has unveiled that the Medical Records are not documented properly in the university hospital where the Medical Records are also used for educational purposes. Such incomplete Medical Records are not reliable resources for medical care too. Some influencing factors external to the structure of the Medical Records (i.e. human factors and work conditions) are involved.

The ANKLe score: an audit of otolaryngology emergency clinic record keeping

INTRODUCTION

Accurate and legible medical records are essential to good quality patient care. Guidelines from The Royal College of Surgeons of England (RCSE) state the content required to form a complete medical record, but do not address legibility. An audit of otolaryngology emergency clinic record keeping was performed using a new scoring system.

PATIENTS AND METHODS

The Adjusted Note Keeping and Legibility (ANKLe) score was developed as an objective and quantitative method to assess both the content and legibility of case notes, incorporating the RCSE guidelines. Twenty consecutive otolaryngology emergency clinic case notes from each of 7 senior house officers were audited against standards for legibility and content using the ANKLe score. A proforma was introduced to improve documentation and handwriting advice was given. A further set of 140 notes (20 notes for each of the 7 doctors) was audited in the same way to provide feedback.

RESULTS

The introduction of a proforma and advice on handwriting significantly increased the quality of case note entries in terms of content, legibility and overall ANKLe score.

CONCLUSIONS

Accurate note keeping can be improved by the use of a proforma. The legibility of handwriting can be improved using simple advice. The ANKLe score is an objective assessment tool of the overall quality of medical note documentation which can be adapted for use in other specialties.

Coding Geriatric syndromes: How good are we?

High quality coding of hospital activity is important because the data is used for resource allocation and measuring performance. There is little information on the quality of coding of admissions of frail older people who have multiple diagnoses, co-morbidities and functional impairment. Presence or absence of four geriatric syndromes and eight medical conditions was noted on case note review (CNR). Discharge summaries (DS) and hospital coding (HC) were reviewed and compared with the CNR. Forty patients had at least one geriatric syndrome noted in the DS; 16 (40.0%) were captured by the HC. Of 57 patients with at least one medical condition noted in the DS, 52 (91.2%) were captured by the HC (p<0.0001 for difference in HC capture rates). We have demonstrated poor capture of information on geriatric syndromes compared to medical conditions in discharge summaries and hospital coding and propose a problem list bookmark approach to improve this.

Comparison of a commercially available clinical information system with other methods of measuring critical care outcomes data

PURPOSE

To compare the quality of data recorded by a commercially available clinical information system (CIS) to other commonly used methods for obtaining large amounts of patient data.

MATERIALS AND METHODS

Five sets of clinical patient data were chosen as a cross-section of all the data collected by a CIS in our intensive care unit (ICU): 1) Length of stay in the ICU, 2) Vital signs, 3) Days of mechanical ventilation, 4) medications, and 5) diagnoses. Data generated by our ICU CIS was compared with other parallel data sets commonly used to obtain the same data for clinical research.

RESULTS

When compared with our CIS, the hospital database recorded a length of stay at least 1 day longer than the actual length of stay 53% of the time. A search of 139,387 sets of vital signs showed less than 0.1% rate of suspected artifact. When compared to direct observation, our CIS correctly recorded days of mechanical ventilation in 23 of 26 patients (88%). Two other data sets, medical diagnoses and medications given showed significant differences with other commonly used databases of the same information collected outside the ICU (billing codes and pharmacy records respectively

CONCLUSIONS

Compared to other commonly used data sources for clinical research, a commercially available CIS is an acceptable source of ICU patient data.

Improving prescribing using a rule based prescribing system

OBJECTIVE

To test the hypothesis that the prescribing behaviour of doctors would improve after having experience with a computerised rule based prescribing system.

DESIGN

A prospective observational study of changes in prescribing habits resulting from the use of a computerised prescribing system in (1) a cohort of experienced users compared with a new cohort, and (2) a single cohort at the beginning and after 3 weeks of computer aided prescribing.

SETTING

64 bed renal unit in a teaching hospital.

INTERVENTION

Routine use of a computerised prescribing system by doctors and nurses on a renal unit from 1 July to 31 August 2001.

MAIN OUTCOME MEASURES

Number of warning messages generated by the system; proportion of warning messages overridden; comparison between doctors of different grades; comparison by doctors' familiarity with the system.

RESULTS

A total of 51,612 records relating to 5995 prescriptions made by 103 users, of whom 42 were doctors, were analysed. The prescriptions generated 15,853 messages, of which 6592 were warning messages indicating prescribing errors or problems. Doctors new to the system generated fewer warning messages after using the system for 3 weeks (0.81 warning messages per prescription v 0.42 after 3 weeks, p = 0.03). Doctors with more experience of the system were less likely to generate a warning message (Spearman's rho = -0.90, p = 0.04) but were more likely to disregard one (Spearman's rho = -1, p<0.01). Senior doctors were more likely than junior doctors to ignore a warning message.

CONCLUSIONS

Doctors are influenced by the experience of using a computerised prescribing system. When judged by the number of warning messages generated per prescription, their prescribing improves with time and number of prescriptions written. Consultants and registrars are more likely to use their clinical judgement to override warning messages regarding prescribed drugs.

Improving prescribing using a rule based prescribing system

OBJECTIVE

To test the hypothesis that the prescribing behaviour of doctors would improve after having experience with a computerised rule based prescribing system.

DESIGN

A prospective observational study of changes in prescribing habits resulting from the use of a computerised prescribing system in (1) a cohort of experienced users compared with a new cohort, and (2) a single cohort at the beginning and after 3 weeks of computer aided prescribing.

SETTING

64 bed renal unit in a teaching hospital.

INTERVENTION

Routine use of a computerised prescribing system by doctors and nurses on a renal unit from 1 July to 31 August 2001.

MAIN OUTCOME MEASURES

Number of warning messages generated by the system; proportion of warning messages overridden; comparison between doctors of different grades; comparison by doctors' familiarity with the system.

RESULTS

A total of 51,612 records relating to 5995 prescriptions made by 103 users, of whom 42 were doctors, were analysed. The prescriptions generated 15,853 messages, of which 6592 were warning messages indicating prescribing errors or problems. Doctors new to the system generated fewer warning messages after using the system for 3 weeks (0.81 warning messages per prescription v 0.42 after 3 weeks, p = 0.03). Doctors with more experience of the system were less likely to generate a warning message (Spearman's rho = -0.90, p = 0.04) but were more likely to disregard one (Spearman's rho = -1, p<0.01). Senior doctors were more likely than junior doctors to ignore a warning message.

CONCLUSIONS

Doctors are influenced by the experience of using a computerised prescribing system. When judged by the number of warning messages generated per prescription, their prescribing improves with time and number of prescriptions written. Consultants and registrars are more likely to use their clinical judgement to override warning messages regarding prescribed drugs.

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