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1.  Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review 
Documentation in medical records fulfills key functions, including management of care, communication, quality assurance and record keeping. We sought to describe: 1) rates of standard prenatal care as documented in medical charts, and given the higher risks with excess weight, whether this documentation varied among normal weight, overweight and obese women; and 2) adherence to obesity guidelines for obese women as documented in the chart.
We conducted a chart review of 300 consecutive charts of women who delivered a live singleton at an academic tertiary centre from January to March 2012, computing Analysis of Variance and Chi Square tests.
The proportion of completed fields on the mandatory antenatal forms varied from 100% (maternal age) to 52.7% (pre-pregnancy body mass index). Generally, documentation of care was similar across all weight categories for maternal and prenatal genetic screening tests, ranging from 54.0% (documentation of gonorrhea/chlamydia tests) to 85.0% (documentation of anatomy scan). Documentation of education topics varied widely, from fetal movement in almost all charts across all weight categories but discussion of preterm labour in only 20.6%, 12.7% and 13.4% of normal weight, overweight and obese women’s charts (p = 0.224). Across all weight categories, documentation of discussion of exercise, breastfeeding and pain management occurred in less than a fifth of charts.
Despite a predominance of excess weight in our region, as well as increasing perinatal risks with increasing maternal weight, weight-related issues and other elements of prenatal care were suboptimally documented across all maternal weight categories, despite an obesity guideline.
PMCID: PMC4065541  PMID: 24927750
Antenatal medical records; Documentation; Guideline adherence; Obesity; Prenatal care
Recording the interaction between a patient and the dentist is of primary importance in dental practice. The completeness of recordings of undergraduate students, often inadequate, has been found to subsequently impact on the quality of dental care offered by professionals. Once identified, correcting the inadequacies has also been shown to improve the quality of dental practice.
We aimed to evaluate the quality of records keeping by dental students in Ibadan, Nigeria.
A retrospective review of records of patients seen by dental students, at the clinics of the dental school in Ibadan, Nigeria, over a six months period was conducted. The charts were reviewed for: demographic data, medical and dental history, clinical findings, diagnosis, treatment plan and note on informed consent. Assessment of the quality of data obtained was done using a modified CRABEL’s scoring system.
A total of 318 case files were retrieved for this study. The median modified CRABEL score was 95%, with a range of 65 to 95%. Eighty-two recordings (25.2%) had a score < 90%, while 236 recordings (74.2%) had a score ≥ 90%. The most frequently unrecorded data was written consent in all the charts, followed by procedure done with the documentation absent in 20.4%. All the supervisors signed at the end of the consultation.
The quality of records keeping by dental undergraduates is fair but there is a need to emphasize deficient areas and improve upon the quality of record keeping.
PMCID: PMC4111046  PMID: 25161401
dental record; students; CRABEL score.
3.  Performance assessment. Family physicians in Montreal meet the mark! 
Canadian Family Physician  2002;48:1337-1344.
OBJECTIVE: To assess the clinical performance of a representative non-volunteer sample of family physicians in metropolitan Montreal, Que. DESIGN: Assessment of clinical performance was based on inspection visits to offices, peer review of medical records, and chart-stimulated recall interviews. The procedure was the one usually followed by the Professional Inspection Committee of the Collège des médecins du Québec. SETTING: Family physicians' practices in metropolitan Montreal. PARTICIPANTS: One hundred randomly selected family physicians. INTERVENTIONS: For each physician, 30 randomly chosen patient charts with data on three to five previous visits were reviewed using explicit criteria and a standard scale using global scores from 1 to 5 (unacceptable to excellent). MAIN OUTCOME MEASURES: Scores were assigned for office practices; record keeping; number of continuing medical education (CME) activities; and quality of clinical performance assessed in terms of investigation plan, diagnostic accuracy, treatment plan, and relevance of care. RESULTS: Overall performance was judged to be good to excellent for 98% of physicians in their private practices; for 90% of physicians concerning CME activities; for 94% of physicians concerning their clinical performance in terms of quality of care; and for 75% of physicians as to record keeping. There was a link between record keeping and quality of care as well as between the number of CME activities and quality of care. CONCLUSION: The overall clinical performance of family physicians in the greater Montreal region is excellent.
PMCID: PMC2214090  PMID: 12228963
4.  Ten-year results of quality assurance in radiotherapy chart round 
The Royal Australian and New Zealand College of Radiologists (RANZCR) initiated a unique instrument to audit the quality of patient notes and radiotherapy prescriptions. We present our experience collected over ten years from the use of the RANZCR audit instrument.
In this study, the results of data collected prospectively from January 1999 to June 2009 through the audit instrument were assessed. Radiotherapy chart rounds were held weekly in the uro-oncology tumour stream and real time feedback was provided. Electronic medical records were retrospectively assessed in September 2009 to see if any omissions were subsequently corrected.
In total 2597 patients were audited. One hundred and thirty seven (5%) patients had one hundred and ninety nine omissions in documentation or radiotherapy prescription. In 79% of chart rounds no omissions were found at all, in 12% of chart rounds one omission was found and in 9% of chart rounds two or more omissions were found. Out of 199 omissions, 95% were of record keeping and 2% were omissions in the treatment prescription. Of omissions, 152 (76%) were unfiled investigation results of which 77 (51%) were subsequently corrected.
Real-time audit with feedback is an effective tool in assessing the standards of radiotherapy documentation in our department, and also probably contributed to the high level of attentiveness. A large proportion of omissions were investigation results, which highlights the need for an improved system of retrieval of investigation results in the radiation oncology department.
PMCID: PMC3639063  PMID: 23617328
Audit; Radiotherapy; Urology; RANZCR; Quality
5.  Family Doctors and Their Records: A Survey in Southern Alberta 
Canadian Family Physician  1978;24:145-148.
A questionnaire about their approach to keeping office records was completed by 82 randomly selected family physicians in southern Alberta. The results suggest that although there were few manifestly inadequate recordkeepers, there were many areas for legitimate concern, especially the following:
1. Extremely brief notes
2. Limited attention to psychosocial data
3. Underutilization of the more efficient filing techniques
4. Poorly organized charts
5. Failure to exploit fully innovations which had been introduced into the records system
6. Inadequate protection of the records.
There is reason to believe that the standard of record-keeping in family practice is improving. A few small, simple changes in our record-keeping habits could effect a considerable acceleration of this process.
PMCID: PMC2379116  PMID: 21301496
6.  Comparison of reading speed with 3 different log-scaled reading charts 
Journal of Optometry  2014;7(4):210-216.
A reading chart that resembles real reading conditions is important to evaluate the quality of life in terms of reading performance. The purpose of this study was to compare the reading speed of UiTM Malay related words (UiTM-Mrw) reading chart with MNread Acuity Chart and Colenbrander Reading Chart.
Materials and methods
Fifty subjects with normal sight were randomly recruited through randomized sampling in this study (mean age = 22.98 ± 1.65 years). Subjects were asked to read three different near charts aloud and as quickly as possible at random sequence. The charts were the UiTM-Mrw Reading Chart, MNread Acuity Chart and Colenbrander Reading Chart, respectively. The time taken to read each chart was recorded and any errors while reading were noted. Reading performance was quantified in terms of reading speed as words per minute (wpm).
The mean reading speed for UiTM-Mrw Reading Chart, MNread Acuity Chart and Colenbrander Reading Chart was 200 ± 30 wpm, 196 ± 28 wpm and 194 ± 31 wpm, respectively. Comparison of reading speed between UiTM-Mrw Reading Chart and MNread Acuity Chart showed no significant difference (t = −0.73, p = 0.72). The same happened with the reading speed between UiTM-Mrw Reading Chart and Colenbrander Reading Chart (t = −0.97, p = 0.55). Bland and Altman plot showed good agreement between reading speed of UiTM-Mrw Reading Chart with MNread Acuity Chart with the Colenbrander Reading Chart.
UiTM-Mrw Reading Chart in Malay language is highly comparable with standardized charts and can be used for evaluating reading speed.
PMCID: PMC4213869  PMID: 25323642
Reading chart; Reading rate; Reading performance; Test de lectura; Índice de lectura; Rendimiento lector
7.  Measuring the success of electronic medical record implementation using electronic and survey data. 
Computerization of physician practices is increasing. Stakeholders are demanding demonstrated value for their Electronic Medical Record (EMR) implementations. We developed survey tools to measure medical office processes, including administrative and physician tasks pre- and post-EMR implementation. We included variables that were expected to improve with EMR implementation and those that were not expected to improve, as controls. We measured the same processes pre-EMR, at six months and 18 months post-EMR. Time required for most administrative tasks decreased within six months of EMR implementation. Staff time spent on charting increased with time, in keeping with our anecdotal observations that nurses were given more responsibility for charting in many offices. Physician time to chart increased initially by 50%, but went down to original levels by 18 months. However, this may be due to the drop-out of those physicians who had a difficult time charting electronically.
PMCID: PMC2243411  PMID: 11825201
8.  Care for Patients with Type 2 Diabetes in a Random Sample of Community Family Practices in Ontario, Canada 
Objective. Diabetes care is an important part of family practice. Previous work indicates that diabetes management is variable. This study aimed to examine diabetes care according to best practices in one part of Ontario. Design and Participants. A retrospective chart audit of 96 charts from 18 physicians was conducted to examine charts regarding diabetes care during a one-year period. Setting. Grimsby, Ontario. Main Outcome Measures. Glycemic screening, control and management strategies, documentation and counselling for lifestyle habits, prevalence of comorbidities, screening for hypertension, hyperlipidemia, and use of appropriate recommended preventive medications in the charts were examined. Results. Mean A1c was within target (less than or equal to 7.00) in 76% of patients (ICC = −0.02), at least 4 readings per annum were taken in 75% of patients (ICC = 0.006). Nearly 2/3 of patients had been counselled about diet, more than 1/2 on exercise, and nearly all (90%) were on medication. Nearly all patients had a documented blood pressure reading and lipid profile. Over half (60%) had a record of their weight and/or BMI. Conclusion. Although room for improvement exists, diabetes targets were mainly reached according to recognized best practices, in keeping with international data on attainment of diabetes targets.
PMCID: PMC3407621  PMID: 22852083
9.  Impact of a Health Communication Intervention to Improve Glaucoma Treatment Adherence: Results of the I-SIGHT Trial 
Archives of ophthalmology  2012;130(10):1252-1258.
To determine the efficacy of an automated, interactive, telephone-based health communication intervention for improving glaucoma treatment adherence among patients in two hospital-based eye clinics.
Randomized controlled trial.
Two eye clinics located in hospitals in the Southeastern United States.
312 glaucoma patients aged 18 to 80 years, non-adherent with medication taking, medication refills, and/or appointment keeping
The treatment group received an automated, interactive, tailored telephone intervention and tailored printed materials. The control group received usual care.
Main Outcome Measures
Adherence with medication taking, prescription refills, and appointment keeping measured by interviews, medical charts, appointment records, and pharmacy data.
A statistically significant increase was found for all adherence measures in both the intervention and control groups. Interactive phone calls and tailored print materials did not significantly improve adherence measures compared to controls.
During the study period, patient adherence to glaucoma treatment and appointment keeping improved in both study arms. Participation in the study and interviews may have contributed. Strategies that address individuals’ barriers and facilitators may increase the impact of telephone calls, especially for appointment keeping and prescription refills.
PMCID: PMC3593648  PMID: 22688429
10.  Predictors of loss to follow-up before HIV treatment initiation in Northwest Ethiopia: a case control study 
BMC Public Health  2013;13:867.
In Ethiopia, there is a growing concern about the increasing rates of loss to follow-up (LTFU) in HIV programs among people waiting to start HIV treatment. Unlike other African countries, there is little information about the factors associated with LTFU among pre-antiretroviral treatment (pre-ART) patients in Ethiopia. We conducted a case–control study to investigate factors associated with pre-ART LTFU in Ethiopia.
Charts of HIV patients newly enrolled in HIV care at Gondar University Hospital (GUH) between September 11, 2008 and May 8, 2011 were reviewed. Patients who were “loss to follow-up” during the pre-ART period were considered to be cases and patients who were “in care” during the pre-ART period were controls. Logistic regression analysis was used to explore factors associated with pre-ART LTFU.
In multivariable analyses, the following factors were found to be independently associated with pre-ART LTFU: male gender [Adjusted Odds Ratio (AOR) = 2.00 (95% CI: 1.15, 3.46)], higher baseline CD4 cell count (251–300 cells/μl [AOR = 2.64 (95% CI: 1.05, 6.65)], 301–350 cells/μl [AOR = 5.21 (95% CI: 1.94, 13.99)], and >350 cells/μl [AOR = 12.10 (95% CI: 6.33, 23.12)] compared to CD4 cell count of ≤200 cells/μl) and less advanced disease stage (WHO stage I [AOR = 2.81 (95% CI: 1.15, 6.91)] compared to WHO stage IV). Married patients [AOR = 0.39 (95% CI: 0.19, 0.79)] had reduced odds of being LTFU. In addition, patients whose next visit date was not documented on their medical chart [AOR = 241.39 (95% CI: 119.90, 485.97)] were more likely to be LTFU.
Our study identified various factors associated with pre-ART LTFU. The findings highlight the importance of giving considerable attention to pre-ART patients’ care from the time that they learn of their positive HIV serostatus. The completeness of the medical records, the standard of record keeping and obstacles to retrieving charts also indicate a serious problem that needs due attention from clinicians and data personnel.
PMCID: PMC3851146  PMID: 24053770
Pre-antiretroviral treatment loss to follow-up; HIV patients; Case control; Ethiopia; Africa
11.  Can one patient record accommodate the diversity of specialized care? 
Despite a quarter century of developments, few specialists directly use a computerized patient record, that fully replaces the paper chart. Because of the diversity of domains in specialized care, medical decision-making and the continuity of care may suffer from scattering of patient data over various records. The challenge was to develop a computerized patient record, that would be versatile enough to tailor it to specific needs, while keeping it uniform enough to permit physicians to share data on the same patient. In our CPR, the key that reconciles versatility with uniformity lies in the design of the data model. The CPR consists of a mother record with specialized sub-records, that all share the same data model. A physician can enlarge his scope for decision-making by consulting other specialized records on the same patient or by viewing the combined information of all sub-records without the need to convert data or to familiarize himself with different interfaces.
PMCID: PMC2579124  PMID: 8563312
12.  A Survey of Data Recording Procedures at New York City Emergency Departments 
To describe the development, implementation, and analysis of a hospital based emergency department (ED) survey and site visit project conducted by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH).
Data is collected daily by the DOHMH from 49 of the 52 NYC EDs, representing approximately 95% of all ED visits in NYC. Variability in data fields between and within EDs has been noticed for some time. Differences in chief complaint (CC) characteristics and inconsistent availability of data elements, such as disposition and diagnosis, suggest that procedures, coding practices and health information systems (HIS) are not standardized across all NYC EDs, and may change within EDs. These differences may have an unapparent effect on the DOHMH’s ability to consistently categorize ED visits into syndrome groupings, which may alter how syndromic trends are analyzed. Prior to this project, the DOHMH had no method in place to regularly capture, evaluate or utilize this level of ED-specific information.
A member of the DOHMH contacted all 49 EDs to request a brief interview with the ED director, administrator and/or appropriate staff. A questionnaire was designed to collect the following information about each ED: the clinical and administrative HIS used to collect patient information and report it to the DOHMH (including any recent system changes); CC coding practices (i.e. who records the CC, and into which HIS, and in what format); disposition and diagnosis recording practices and availability. Questions regarding hospital specific trends and characteristics were also included. Interviews were conducted in person by two members of the DOHMH.
Information from the survey was compiled into a Microsoft Excel spreadsheet by the interviewers. A descriptive analysis was performed comparing and detailing HIS used, CC coding practices, and recording procedures for disposition and diagnosis. A member of the DOHMH followed up with ED staff and IT personnel to resolve any outstanding data quality issues.
All 49 EDs were contacted and interviewed. A median of 43 days (ranging from 7 to 167) elapsed between the initial attempt to contact the ED director, and the completion of the interview. All interviews lasted approximately 40 minutes.
According to the results of the survey, the DOHMH receives information from the clinical HIS from approximately 20% of EDs, from the administrative HIS from approximately 70% of the EDs, and approximately 10% of the EDs did not know which system was used to generate the daily reports sent to the DOHMH. Nearly 100% of the EDs reported that the chief complaint was entered into the clinical HIS by a triage nurse. However, it is not known who records the CC into the administrative system. Four EDs reported that a drop-down menu is used to record CC into the clinical HIS, 23 EDs CC is in free-text format, and 22 EDs CC is a combination of free-text and drop-down format.
Diagnosis was recorded by the physician at 45% of the EDs, and by other staff, including nurses and clerks, at 55% of the EDs. Two thirds of the EDs reported a lag time of less than one week between the visit and assignment of diagnosis codes. Disposition is recorded by the physician at 80% of EDs. Discharge disposition is often required for a patients chart to be considered complete.
As a result of the visits the DOHMH was able to better understand problems that cause routine data quality problems (e.g. missing data or unusable data) by hospital and identify methods to improve those problems. Missing and up to date disposition codebooks were obtained from hospitals. Current hospital contacts were identified for follow up.
Discussions with hospital personnel regarding specific trends, characteristics and interests helped to strengthen the relationship the DOHMH has with the hospital ED staff.
Differences in practices, procedures, and HIS used can lead to variability in data quality and characteristics which may affect the ability to categorize visits into effective syndrome groupings and understand trends. Further research is needed to develop an improved method for analyzing ED data that takes ED-specific characteristics into consideration. Additionally, it is important to establish good working relationships with key members of each ED’s staff in the event of a possible outbreak, and in keeping up to date on any changes within each ED that may affect data quality.
PMCID: PMC3692759
Emergency Department; Syndromic Surveillance; Coding Practices
13.  Analysis of the Medical Records in a Pediatric Emergency Room 
A prospective evaluation of Pediatric Emergency Room records permitted analysis of major errors and of factors contributing to them. All records from July 1973 to June 1975 were reviewed daily by a board certified pediatrician using a previously established protocol. Patients had been seen by pediatric house staff from 4 PM to 8 AM on weekdays and from 8 AM to 8 AM on weekends and 25,907 records were reviewed. Errors were detected in 9.5 percent of these. The most common was an incomplete set of vital signs which accounts for 68 percent of all errors. Failure to arrange for appropriate follow-up care occurred in 16 percent of cases. Other errors ranged from two to four percent and included inadequate use of laboratory, incomplete physical examination, inappropriate diagnosis or therapy. Major omissions in the history were uncommon (1.3 percent). The frequency of errors was significantly greater at the start of each academic year (July to October), and at the start of each month (P<0.001). The errors occurred significantly more often at the first year level than the second year level (P<0.01). This study suggests a means of improving record keeping and house staff education, ie, attending-level supervision should be emphasized at the start of each month and academic year. Daily reviews of errors with the house staff as well as modification of chart design may bring about more complete patient evaluation and detailed recording of findings, diagnosis, and disposition.
PMCID: PMC2537309  PMID: 480393
14.  Documentation of growth parameters and body mass index in a paediatric hospital 
Paediatrics & Child Health  2005;10(7):391-394.
New recommendations suggest that the 2000 Centers for Disease Control and Prevention (CDC) growth charts and body mass index (BMI) for age be used for Canadian children. Little information is available on how often growth parameters are documented in hospital settings.
To determine the frequency of documentation of growth parameters in the medical records of a tertiary care paediatric hospital.
A prospective, 14-day audit of 491 charts of children seen in the emergency department (ED) or admitted to a ward was performed to determine the frequency of documentation of height/length, weight, head circumference, BMI or weight for height, and presence of growth charts. Similar data were sought from the most recent clinic visit for all ward charts.
Growth parameters, aside from weight, were infrequently documented in the medical record. Height/length was documented in no ED charts and in 42% of ward charts. BMI or weight for height were almost never found, and growth charts were present in only 23% of ward charts, one clinic chart and one ED chart.
Rates of documentation of growth parameters in the teaching hospital setting were unacceptably low. Implementation of the use of the 2000 CDC growth charts will require not only education regarding BMI but also steps to encourage more regular measurement of height and use of shared growth charts in all areas of the hospital. A simple conceptualization framework for health care providers to use as a counselling tool is presented.
PMCID: PMC2722559  PMID: 19668645
Audit; Body mass index; Green zone; Growth; Growth chart
15.  Identifying Adverse Drug Events 
Abstract Background: Adverse drug events (ADEs) are both common and costly. Most hospitals identify ADEs using spontaneous reporting, but this approach lacks sensitivity; chart review identifies more events but is expensive. Computer-based approaches to ADE identification appear promising, but they have not been directly compared with chart review and they are not widely used.
Objectives: To develop a computer-based ADE monitor, and to compare the rate and type of ADEs found with the monitor with those discovered by chart review and by stimulated voluntary report.
Design: Prospective cohort study in one tertiary-care hospital.
Participants: All patients admitted to nine medical and surgical units in a tertiary-care hospital over an eight-month period.
Main Outcome Measure: Adverse drug events identified by the computer-based monitor, by chart review, and by stimulated voluntary report.
Methods: A computer-based monitoring program identified alerts, which were situations suggesting that an ADE might be present (e.g., an order for an antidote such as naloxone). A trained reviewer then examined patients' hospital records to determine whether an ADE had occurred. The results of the computer-based monitoring strategy were compared with two other ADE detection strategies: intensive chart review and stimulated voluntary report by nurses and pharmacists. The monitor and the chart review strategies were independent, and the reviewers were blinded.
Results: The computer monitoring strategy identified 2,620 alerts, of which 275 were determined to be ADEs. The chart review found 398 ADEs, whereas voluntary report detected 23. Of the 617 ADEs detected by at least one method, 76 ADEs were detected by both computer monitor and chart review. The computer monitor identified 45 percent; chart review, 65 percent; and voluntary report, 4 percent. The ADEs identified by computer monitor were more likely to be classified as “severe” than were those identified by chart review (51 versus 42 percent, p =.04). The positive predictive value of computer-generated alerts was 16 percent during the first eight weeks of the study; rule modifications increased this to 23 percent in the final eight weeks. The computer strategy required 11 person-hours per week to execute, whereas chart review required 55 person-hours per week and voluntary report strategy required 5.
Conclusions: The computer-based monitor identified fewer ADEs than did chart review but many more ADEs than did stimulated voluntary report. The overlap among the ADEs identified using different methods was small, suggesting that the incidence of ADEs may be higher than previously reported and that different detection methods capture different events. The computer-based monitoring system represents an efficient approach for measuring ADE frequency and gauging the effectiveness of ADE prevention programs.
PMCID: PMC61304  PMID: 9609500
16.  Contamination of Medical Charts: An Important Source of Potential Infection in Hospitals 
PLoS ONE  2014;9(2):e78512.
This prospective study aims to identify and compare the incidence of bacterial contamination of hospital charts and the distribution of species responsible for chart contamination in different units of a tertiary hospital.
All beds in medical, surgical, pediatric, and obstetric-gynecologic general wards (556) and those in corresponding special units (125) including medical, surgical, pediatric intensive care units (ICUs), the obstetric tocolytic unit and delivery room were surveyed for possible chart contamination. The outer surfaces of included charts were sampled by one experienced investigator with sterile cotton swabs rinsed with normal saline.
For general wards and special units, the overall sampling rates were 81.8% (455/556) and 85.6% (107/125) (p = 0.316); the incidence of chart contamination was 63.5% and 83.2%, respectively (p<0.001). Except for obstetric-gynecologic charts, the incidence was significantly higher in each and in all ICUs than in corresponding wards. Coagulase-negative staphylococci was the most common contaminant in general wards (40.0%) and special units (34.6%) (p>0.05). Special units had a significantly higher incidence of bacterial contamination due to Staphylococcus aureus (17.8%), Methicillin-resistant Staphylococcus aureus (9.3%), Streptococcus viridans (9.4%), Escherichia coli (11.2%), Klebsiella pneumoniae (7.5%), and Acinetobacter baumannii (7.5%). Logistic regression analysis revealed the incidence of chart contamination was 2- to 4-fold higher in special units than in general wards [odds ratios: 1.97–4.00].
Noting that most hospital charts are contaminated, our study confirms that a hospital chart is not only a medical record but also an important source of potential infection. The plastic cover of the medical chart can harbor potential pathogens, thus acting as a vector of bacteria. Additionally, chart contamination is more common in ICUs. These findings highlight the importance of effective hand-washing before and after handling medical charts. However, managers and clinical staff should pay more attention to the issue and may consider some interventions.
PMCID: PMC3928153  PMID: 24558355
17.  Recording blood pressure readings in elderly patients’ charts 
Canadian Family Physician  2008;54(2):230-231.
To identify patient and physician characteristics associated with family physicians recording blood pressure (BP) measurements in the medical charts of their elderly patients.
Retrospective review of patients’ charts during a 12-month period and baseline questionnaire on the sociodemographic and practice characteristics of family physicians participating in the Community Hypertension Assessment Trial. The chart review collected data on patients’ demographics, cardiovascular risk factors, antihypertensive medications, number of visits to family physicians, and number of BP readings recorded.
Non-academic family practices in Hamilton and Ottawa, Ont.
Data were abstracted from the charts of 55 randomly selected regular elderly patients (65 years old and older) from each of 28 participating family practices (N = 1540 charts).
Number of recordings of BP measurements in medical charts during a 12-month period.
About 16% (241/1540) of elderly patients had not had their BP recorded in their charts during the 12-month review period. Among this 16%, almost half (47%, 114/241) had not had a BP measurement recorded during the previous 24 months. Multivariate analysis indicated that the likelihood of BP recording increased with the number of visits made to family physicians and was greater among patients taking antihypertensive medications or diagnosed with hypertension. Physicians who had more recently graduated from medical school (≤ 24 years) were more likely to record BP measurements.
Hypertension guidelines recommend that, for patients at risk, BP be measured and recorded at each office visit. Although more than 84% of older patients had at least 1 BP reading documented in their charts, patients who were already diagnosed with hypertension or who made frequent visits to the office were more likely to have their BP measured and recorded. A more systematic approach to monitoring elderly patients who visit their family physicians less frequently or who are not currently diagnosed with hypertension is needed.
PMCID: PMC2278315  PMID: 18272639
18.  Central venous lines in neonates: a study of 2186 catheters 
Design: Data for all infants admitted from 1 January 1984 until 31 December 2002 who had a CVL were examined in the neonatal database, completed from paper records and patient charts where necessary. Autopsy reports of all babies who died with a catheter in place were reviewed.
Results: There were 18 761 admissions, 2186 catheters in 1862 babies for a total of 35 159 days (median 14 days, range 1–99 days). The tip was in the right atrium for 1282 (58.6%) of the catheters. A total of 142 babies (7.6%) died with a CVL in place, 89 (4.8%) with the catheter tip in the right atrium. Thirty two of these 89 babies had an autopsy. No autopsies reported tension in the pericardium or milky fluid resembling intralipid. One case (0.05% of catheters) of non-lethal pericardial effusion occurred in a baby whose catheter was inappropriately left coiled in the right atrium. There were no cases of pleural effusion related to CVL use. Most (1523, 69.7%) were removed electively. Septicaemia occurred during the life of 116 catheters (5.3%).
Conclusion: This is the largest series of percutaneously inserted silicone central venous catheters reported. It illustrates the safety of these catheters in this context. It highlights the value of keeping prospective records on such catheters. Catheters with their tips in the right atrium and not coiled did not cause pericardial effusion. Strict insertion and management principles for CVLs should be adhered to.
PMCID: PMC1721795  PMID: 15499142
19.  Clinician Perceptions of Pediatric Growth Chart Use and Electronic Health Records in Kentucky 
Applied Clinical Informatics  2012;3(4):437-447.
Growth chart recording is a key component of pediatric care. EHR systems could provide several growth charting functionalities compared to paper methods. To our knowledge, there has been no U.S. study exploring clinicians’ perceptions and practices related to recording of growth parameters as they adapt to electronic methods.
To explore clinician practices regarding recording growth parameters as they adapt to electronic health records (EHR) and to investigate clinician perceptions of electronic growth charting using EHR.
An online survey of pediatricians and family practitioners in Kentucky inquiring about EHR usage, specifically use of growth charting with EHR, was conducted.
Forty-six percent of respondents utilized EHRs, with pediatricians lagging family practitioners, and academic pediatricians lagging non-academicians. There was no consensus on EHR platforms being used. Almost a third of those who used EHR did not utilize electronic growth charting. Clinicians using EHR reported that electronic growth charts would improve clinician satisfaction and clinical efficiency as well as parent satisfaction and parent education. Only 12% of respondents provided copies of growth charts to parents at the end of their visit and discussed growth parameters with parents, with clinicians using EHR more likely to engage in these activities than non-EHR users.
Although Kentucky clinicians continue to slowly adopt EHRs, clinician perceptions and practices reflect enduring barriers to widespread use of electronic growth charting in pediatric and family practice. However, our results suggest that electronic growth charting has important benefits for both clinicians and patients, and greater adoption is expected as EHRs become standard across health care systems.
PMCID: PMC3613041  PMID: 23646089
Growth charts; pediatrics; family practice; electronic health record
20.  Medical records and issues in negligence 
It is very important for the treating doctor to properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues. Medical records form an important part of the management of a patient. It is important for the doctors and medical establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, and to plan treatment protocols. It also helps in planning governmental strategies for future medical care. But of equal importance in the present setting is in the issue of alleged medical negligence. The legal system relies mainly on documentary evidence in a situation where medical negligence is alleged by the patient or the relatives. In an accusation of negligence, this is very often the most important evidence deciding on the sentencing or acquittal of the doctor. With the increasing use of medical insurance for treatment, the insurance companies also require proper record keeping to prove the patient's demand for medical expenses. Improper record keeping can result in declining medical claims. It is disheartening to note that inspite of knowing the importance of proper record keeping it is still in a nascent stage in India. It is wise to remember that “Poor records mean poor defense, no records mean no defense”. Medical records include a variety of documentation of patient's history, clinical findings, diagnostic test results, preoperative care, operation notes, post operative care, and daily notes of a patient's progress and medications. A properly obtained consent will go a long way in proving that the procedures were conducted with the concurrence of the patient. A properly written operative note can protect a surgeon in case of alleged negligence due to operative complications. It is important that the prescription for drugs should be legible with the name of the patient, date, and the signature of the doctor. An undated prescription can land a doctor in trouble if the patient misuses it. There are also many records that are indirectly related to patient management such as accounts records, service records of the staff, and administrative records, which are also useful as evidences for litigation purposes. Medical recording needs the concerted effort of a number of people involved in patient care. The doctor is the prime person who has to oversee this process and is primarily responsible for history, physical examination, treatment plans, operative records, consent forms, medications used, referral papers, discharge records, and medical certificates. There should be proper recording of nursing care, laboratory data, reports of diagnostic evaluations, pharmacy records, and billing processes. This means that the paramedical and nursing staff also should be trained in proper maintenance of patient records. The medical scene in India extends from smaller clinics to large hospitals. Medical record keeping is a specialized area in bigger teaching and corporate hospitals with separate medical records officers handling these issues. However, it is yet to develop into a proper process in the large number of smaller clinics and hospitals that cater to a large section of the people in India.
PMCID: PMC2779965  PMID: 19881136
Medical records; medical negligence
21.  Assessing Data Quality in Manual Entry of Ventilator Settings 
To evaluate the data quality of ventilator settings recorded by respiratory therapists using a computer charting application and assess the impact of incorrect data on computerized ventilator management protocols.
An analysis of 29,054 charting events gathered over 12 months from 678 ventilated patients (1,736 ventilator days) in four intensive care units at a tertiary care hospital.
Ten ventilator settings were examined, including fraction of inspired oxygen (Fio 2), positive end-expiratory pressure (PEEP), tidal volume, respiratory rate, peak inspiratory flow, and pressure support. Respiratory therapists entered values for each setting approximately every two hours using a computer charting application. Manually entered values were compared with data acquired automatically from ventilators using an implementation of the ISO/IEEE 11073 Medical Information Bus (MIB). Data quality was assessed by measuring the percentage of time that the two sources matched. Charting delay, defined as the interval between data observation and data entry, also was measured.
The percentage of time that settings matched ranged from 99.0% (PEEP) to 75.9% (low tidal volume alarm setting). The average charting delay for each charting event was 6.1 minutes, including an average of 1.8 minutes spent entering data in the charting application. In 559 (3.9%) of 14,263 suggestions generated by computerized ventilator management protocols, one or more manually charted setting values did not match the MIB data.
Even at institutions where manual charting of ventilator settings is performed well, automatic data collection can eliminate delays, improve charting efficiency, and reduce errors caused by incorrect data.
PMCID: PMC2244881  PMID: 17329731
22.  A computational model for preplay in the hippocampus 
The hippocampal network produces sequences of neural activity even when there is no time-varying external drive. In offline states, the temporal sequence in which place cells fire spikes correlates with the sequence of their place fields. Recent experiments found this correlation even between offline sequential activity (OSA) recorded before the animal ran in a novel environment and the place fields in that environment. This preplay phenomenon suggests that OSA is generated intrinsically in the hippocampal network, and not established by external sensory inputs. Previous studies showed that continuous attractor networks with asymmetric patterns of connectivity, or with slow, local negative feedback, can generate sequential activity. This mechanism could account for preplay if the network only represented a single spatial map, or chart. However, global remapping in the hippocampus implies that multiple charts are represented simultaneously in the hippocampal network and it remains unknown whether the network with multiple charts can account for preplay. Here we show that it can. Driven with random inputs, the model generates sequences in every chart. Place fields in a given chart and OSA generated by the network are highly correlated. We also find significant correlations, albeit less frequently, even when the OSA is correlated with a new chart in which place fields are randomly scattered. These correlations arise from random correlations between the orderings of place fields in the new chart and those in a pre-existing chart. Our results suggest two different accounts for preplay. Either an existing chart is re-used to represent a novel environment or a new chart is formed.
PMCID: PMC3824291  PMID: 24282402
continuous attractor neural networks; multi-chart structure; spike-frequency-adaptation; sequential activity; preplay
23.  Cumulative Patient Profile 
Canadian Family Physician  1989;35:1259-1261.
Traditional record-keeping in family practice, based on the model of hospital charts, gives rise to some serious problems, illustrated in this article by a patient with an allergy to penicillin. The “cumulative patient profile,” which separates pertinent information in the history from the continually updated information on short-term problems, can prevent repetitive history-taking and can make information easily accessible to busy physicians.
PMCID: PMC2280411
cumulative patient profile; data base management; patient records
24.  Clinical Psychologists’ Firearm Risk Management Perceptions and Practices 
Journal of Community Health  2010;35(1):60-67.
The purpose of this study was to investigate the current perceptions and practices of discussing firearm risk management with patients diagnosed with selected mental health problems. A three-wave survey was mailed to a national random sample of clinical psychologists and 339 responded (62%). The majority (78.5%) believed firearm safety issues were greater among those with mental health problems. However, the majority of clinical psychologists did not have a routine system for identifying patients with access to firearms (78.2%). Additionally, the majority (78.8%) reported they did not routinely chart or keep a record of whether patients owned or had access to firearms. About one-half (51.6%) of the clinical psychologists reported they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others. Almost half (46%) of clinical psychologists reported not receiving any information on firearm safety issues. Thus, the findings of this study suggest that a more formal role regarding anticipatory guidance on firearms is needed in the professional training of clinical psychologists.
PMCID: PMC2816245  PMID: 20094905
Suicide; Firearms; Risk; Assessment; Homicide; Mental health
25.  APRIL—The Evolution of a Long Term Care System 
This paper describes a computerized medical information system for long term care, which is relatively unexplored in automated medical record-keeping. APRIL* includes accounting, billing, census, payroll and elderly housing (HUD) systems as well, to enable a facility to use a single computer for all areas. The medical applications include physicians' orders, medication, treatment, restorative nursing care charts, functional and psychological assessments, patient care plans, utilization review summaries, and scheduling for certification of need for care, U.R. meetings, care planning, immunizations, doctor visits, clinic and consult visits, and laboratory, x-ray, EKG, and other tests and monitors. Current plans include production of R.N., L.P.N. and aide task lists, calculating of hours of care required based on problems and documented orders, procedures, and plans.
The programs run on Digital's PDP 11's, including the Micro/J-11, and use the RSTS/E operating system, and the BASIC PLUS language. There are facilities in five (5) states using APRIL*, both batch and online, and several scheduled for in house installation before the end of 1983.
PMCID: PMC2578326

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