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1.  Improving non-invasive ventilation documentation 
BMJ Quality Improvement Reports  2014;3(1):u203278.w1486.
Record keeping for patients on non-invasive ventilation (NIV) at St. Georges Hospital is poor. The initial NIV prescription is often not recorded, and changes to the NIV prescription or the rationale for the changes (ABG results) are also poorly documented. This leads to confusion for nurses/doctors as to what the correct settings are, meaning patients could receive ineffective ventilation. The use of NIV is also poorly recorded by nursing staff meaning that doctors are unsure if the prescribed NIV is being achieved. This can lead to treatment being escalated unnecessarily in the event of treatment failure.
Non-invasive ventilation (NIV) is the provision of ventilatory support in the form of positive pressure via the patient's upper airway using a mask or similar device. NIV is indicated for treatment of acute hypercapnic respiratory failure, of which there are many causes, though COPD is the indication in up to 70% of cases.[1] British Thoracic Society (BTS) guidelines for NIV suggest that the rationale for commencing a patient on NIV and the proposed settings should be clearly documented.[2] Clinicians cannot effectively tailor changes to the patients NIV settings if this information is not clearly recorded, which could lead to increased time requiring NIV or NIV failure.
Three main areas were considered important to measure for this project. The initial prescription of the NIV, changes to the NIV settings, and nursing documentation surrounding NIV. A baseline measurement of NIV documentation for two weeks found NIV documentation to globally very poor. NIV was formally prescribed 29% of the time, full detail of intended settings were documented 57% of the time, the decision to commence NIV was discussed with the respiratory consultant/SpR just 29% of the time and on no occasion was a decision regarding escalation of treatment recorded. Eighteen changes were made to the NIV settings. These were formally prescribed 22% of the time and detail of the intended settings was recorded 44% of the time. Nursing documentation included detail on the length of NIV use just 21% of the time, and comments on the NIV use were left just 33% of the time.
The intervention was a unified four page NIV prescription chart. Page 1: An area for the NIV to be initially prescribed with reminder questions for important considerations. Page 2: An area for changes to be made to the NIV settings. Page 3: An area for the most up to date NIV/respiratory plan to be documented. Page 4: Nursing documentation, with prompts for the time NIV was put on/off and for comments. The chart was printed at St Georges print services and paid for by the respiratory ward.
A further two weeks of monitoring followed after implementation of the new chart. Improvements were seen in all areas of documentation surrounding NIV. The NIV was formally prescribed 86% of the time compared to 29% pre-intervention. The NIV settings were stated 100% of the time in the initial prescription. An escalation decision was recorded 71% of the time. Changes to the NIV settings improved to 92%. Nursing documentation improved greatly. The length of the NIV use was recorded for 91% of NIV days compared to 21% previously (p<0.001), and comments on the use of NIV improved from from 33% to 98% (p<0.001). Cases where the documentation remained poor were in those patients for whom the new chart had not been used.
The implementation of a unified NIV prescription chart to be kept in the bedside notes on the respiratory ward greatly improved documentation surrounding NIV. Further work must be done to ensure that the chart is used 100% of the time. This will include adjusting the chart to reduce the workload to use it, rolling the chart out on the acute medical ward, and submitting the chart to the trust board for its acceptance as an official trust chart.
doi:10.1136/bmjquality.u203278.w1486
PMCID: PMC4645943  PMID: 26734310
2.  Documentation of guideline adherence in antenatal records across maternal weight categories: a chart review 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2393-14-205
PMCID: PMC4065541  PMID: 24927750
Antenatal medical records; Documentation; Guideline adherence; Obesity; Prenatal care
3.  QUALITY OF RECORDS KEEPING BY UNDERGRADUATE DENTAL STUDENTS IN IBADAN, NIGERIA 
Background:
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.
Objective:
We aimed to evaluate the quality of records keeping by dental students in Ibadan, Nigeria.
Method:
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.
Results:
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.
Conclusion:
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.
4.  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
5.  Ten-year results of quality assurance in radiotherapy chart round 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1472-6963-13-148
PMCID: PMC3639063  PMID: 23617328
Audit; Radiotherapy; Urology; RANZCR; Quality
6.  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
7.  Comparison of reading speed with 3 different log-scaled reading charts 
Journal of Optometry  2014;7(4):210-216.
Background
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).
Results
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.
Conclusion
UiTM-Mrw Reading Chart in Malay language is highly comparable with standardized charts and can be used for evaluating reading speed.
doi:10.1016/j.optom.2013.12.009
PMCID: PMC4213869  PMID: 25323642
Reading chart; Reading rate; Reading performance; Test de lectura; Índice de lectura; Rendimiento lector
8.  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
9.  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.
doi:10.1155/2012/734202
PMCID: PMC3407621  PMID: 22852083
10.  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.
Objective
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.
Method
Randomized controlled trial.
Setting
Two eye clinics located in hospitals in the Southeastern United States.
Participants
312 glaucoma patients aged 18 to 80 years, non-adherent with medication taking, medication refills, and/or appointment keeping
Intervention
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.
Results
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.
Conclusions
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.
doi:10.1001/archophthalmol.2012.1607
PMCID: PMC3593648  PMID: 22688429
11.  Predictors of loss to follow-up before HIV treatment initiation in Northwest Ethiopia: a case control study 
BMC Public Health  2013;13:867.
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2458-13-867
PMCID: PMC3851146  PMID: 24053770
Pre-antiretroviral treatment loss to follow-up; HIV patients; Case control; Ethiopia; Africa
12.  Lack of weight recording in patients being administered narrow therapeutic index antibiotics: a prospective cross-sectional study 
BMJ Open  2015;5(4):e006092.
Objectives
Patient weight is a key measure for safe medication management and monitoring of patients. Here we report the recording of patient's body weight on admission in three hospitals in West London and its relationship with the prescription of antibiotic drugs where it is essential to have the body weight of the patient.
Methods
A prospective cross-sectional study was conducted in three teaching hospitals in West London. Data were collected during March 2011–September 2011 and July 2012–August 2012, from adult admissions units, medical and surgical wards. Data from each ward were collected on a single day to provide a point prevalence data on weight recording. Patient medication charts, nursing and medical notes were reviewed for evidence of weight and height recording together with all the medication prescribed for the patients. An observational study collecting data on the weight recording process was conducted on two randomly selected wards to add context to the data.
Results
Data were collected on 1012 patients. Weight was not recorded for 46% (474) of patients. Eighty-nine patients were prescribed a narrow therapeutic antibiotic, in 39% (35/89) of these weight was not recorded for the patient. Intravenous vancomycin was the most commonly prescribed antibiotic requiring therapeutic monitoring. In total 61 patients were receiving intravenous vancomycin and of these 44% (27/61) did not have their weight recorded. In the observational study, the most frequently identified barrier to weight not being recorded was interruptions to the admission process.
Conclusions
Despite the clinical importance of body weight measurement it is poorly recorded in hospitalised patients, due to interruptions to the workflow and heavy staff workloads. In antibiotics a correct, recent patient weight is required for accurate dosing and to keep drugs within the narrow therapeutic index, to ensure efficacy of prescribing and reduce toxicity.
doi:10.1136/bmjopen-2014-006092
PMCID: PMC4390734  PMID: 25838504
THERAPEUTICS
13.  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
14.  A Survey of Data Recording Procedures at New York City Emergency Departments 
Objective
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).
Introduction
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.
Methods
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.
Results
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.
Conclusions
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
15.  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
16.  Documentation of growth parameters and body mass index in a paediatric hospital 
Paediatrics & Child Health  2005;10(7):391-394.
BACKGROUND
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.
OBJECTIVE
To determine the frequency of documentation of growth parameters in the medical records of a tertiary care paediatric hospital.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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
17.  Quality Measure Performance in Small Practices Before and After Electronic Health Record Adoption 
eGEMs  2015;3(1):1131.
Introduction:
To date, little research has been published on the impact that the transition from paper-based record keeping to the use of electronic health records (EHR) has on performance on clinical quality measures. This study examines whether small, independent medical practices improved in their performance on nine clinical quality measures soon after adopting EHRs.
Methods:
Data abstracted by manual review of paper and electronic charts for 6,007 patients across 35 small, primary care practices were used to calculate rates of nine clinical quality measures two years before and up to two years after EHR adoption.
Results:
For seven measures, population-level performance rates did not change before EHR adoption. Rates of antithrombotic therapy and smoking status recorded increased soon after EHR adoption; increases in blood pressure control occurred later. Rates of hemoglobin A1c testing, BMI recorded, and cholesterol testing decreased before rebounding; smoking cessation intervention, hemoglobin A1c control and cholesterol control did not significantly change.
Discussion:
The effect of EHR adoption on performance on clinical quality measures is mixed. To improve performance, practices may need to develop new workflows and adapt to different documentation methods after EHR adoption.
Conclusions:
In the short term, EHRs may facilitate documentation of information needed for improving the delivery of clinical preventive services. Policies and incentive programs intended to drive improvement should include in their timelines consideration of the complexity of clinical tasks and documentation needed to capture performance on measures when developing timelines, and should also include assistance with workflow redesign to fully integrate EHRs into medical practice.
doi:10.13063/2327-9214.1131
PMCID: PMC4371508  PMID: 25848635
Quality Improvement; Health Information Technology; Health Policy
18.  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
19.  Contamination of Medical Charts: An Important Source of Potential Infection in Hospitals 
PLoS ONE  2014;9(2):e78512.
Objective
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.
Methods
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.
Results
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].
Conclusions
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.
doi:10.1371/journal.pone.0078512
PMCID: PMC3928153  PMID: 24558355
20.  Which Medication Is the Patient Taking at Admission to the Emergency Ward? Still Unclear Despite the Swedish Prescribed Drug Register 
PLoS ONE  2015;10(6):e0128716.
Introduction
Correct information on patients’ medication is crucial for diagnosis and treatment in the Emergency Department. The aim of this study was to investigate the concordance between the admission chart and two other records of the patient’s medication.
Methods
This cohort study includes data on 168 patients over 18 years admitted to the Emergency Ward between September 1 and 30, 2008. The record kept by the general practitioner and the patient record of dispensed drugs in the Swedish Prescribed Drug Register were compared to the admission chart record.
Results
Drug record discrepancies of potential clinical significance between the admission chart record and the Swedish Prescribed Drug Register or general practitioner record were present in 79 and 82 percent, respectively. For 63 percent of the studied patients the admission chart record did not include all drugs registered in the Swedish Prescribed Drug Register. For 62 percent the admission chart record did not include all drugs registered in the general practitioner record. In addition, for 32 percent of the patients the admission chart record included drugs not registered in the Swedish Prescribed Drug Register and for 52 percent the admission chart record included drugs not found in the general practitioner record. The most discordant drug classes were cardiovascular and CNS-active drugs. Clinically significant drug record discrepancies were more frequent in older patients with multiple medication and caregivers.
Conclusion
The apparent absence of an accurate record of the patient’s drugs at admission to the Emergency Ward constitutes a potential patient safety hazard. The available sources in Sweden, containing information on the drugs a particular patient is taking, do not seem to be up to date. These results highlight the importance of an accurate list of currently used drugs that follows the patient and can be accessed upon acute admission to the hospital.
doi:10.1371/journal.pone.0128716
PMCID: PMC4466313  PMID: 26068920
21.  Recording blood pressure readings in elderly patients’ charts 
Canadian Family Physician  2008;54(2):230-231.
OBJECTIVE
To identify patient and physician characteristics associated with family physicians recording blood pressure (BP) measurements in the medical charts of their elderly patients.
DESIGN
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.
SETTING
Non-academic family practices in Hamilton and Ottawa, Ont.
PARTICIPANTS
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).
MAIN OUTCOME MEASURE
Number of recordings of BP measurements in medical charts during a 12-month period.
RESULTS
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.
CONCLUSION
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
22.  Test Re-Test Reliability and Validity of Different Visual Acuity and Stereoacuity Charts Used in Preschool Children 
Background
Preschool vision screenings are cost effective ways to detect children with vision impairments. The use of any vision tests in children must be age appropriate, testable, repeatable and valid.
Aim
To compare the test re-test reliability, sensitivity and specificity of different visual acuity and stereo acuity charts used in preschool children.
Materials and Methods
Monocular visual acuity of 90 subjects (180 eyes) of age 36 to 71 months was assessed with HOTV, Lea and E-chart in a preschool located in a semi urban area, Manipal, Karnataka. After the vision assessment, stereo acuity was recorded using Frisby and Titmus stereo charts followed by comprehensive eye examination. Repeated measurements of visual acuity and stereo acuity were done one week after the initial assessment.
Results
Mean age of children was 53± 10 months with equal gender distribution. Intra class correlation (ICC) of Lea, HOTV, E-chart, Frisby and Titmus charts were 0.96, 0.99, 0.92, 1.0 and 1.0 respectively. The area under receiver operating curve (ROC) for Lea and E-chart was 0.892 and 0.776. HOTV was considered as the gold standard as it showed the least difference on repeated measurements. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of E-chart was 99, 15, 45, 94 and 21.8 percent, and Lea was 93, 56, 59 and 92 percent. The sensitivity, specificity, PPV and NPV of Frisby was 75, 27, 9, 92 percent were as of Titmus was 75, 13, 8 and 85 percent respectively.
Conclusion
HOTV chart can be used as the gold standard for measuring visual acuity of pre-schoolers in a semi urban area. Lea chart can be used in the absence of HOTV chart. Frisby and Titmus charts are good screening tools, but with poor diagnostic criteria.
doi:10.7860/JCDR/2015/14407.6747
PMCID: PMC4668442  PMID: 26675120
Amblyopia; Depth perception; Screening; Visual acuity
23.  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.
doi:10.1136/adc.2004.049189
PMCID: PMC1721795  PMID: 15499142
24.  Clinician Perceptions of Pediatric Growth Chart Use and Electronic Health Records in Kentucky 
Applied Clinical Informatics  2012;3(4):437-447.
Background
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.
Objectives
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.
Methods
An online survey of pediatricians and family practitioners in Kentucky inquiring about EHR usage, specifically use of growth charting with EHR, was conducted.
Results
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.
Conclusion
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.
doi:10.4338/ACI-2012-06-RA-0023
PMCID: PMC3613041  PMID: 23646089
Growth charts; pediatrics; family practice; electronic health record
25.  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.
doi:10.4103/0970-1591.56208
PMCID: PMC2779965  PMID: 19881136
Medical records; medical negligence

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