Contemporaneous Documentation Research Articles

Ending a Treatment Relationship

Ending a Treatment Relationship

O50 - Being with computer: Midwives’ perspectives of the impact of the electronic maternity record on their practice providing woman-centred care

Increasingly midwives are using digital technology in place of handheld records to record and document midwifery care across the continuum of care in both community and hospital settings. A rationale for this change has been the purported benefits of electronic health records (EHR) in reducing errors of omission, duplication, transcription, and interpretation that are caused by unclear, illegible, absent, and lost information. However, both positive and negative features of EHRs have been reported by clinicians. The objectives of this study were to explore midwives’ experiences using the integrated electronic maternity record (EMR) and their perspectives on the impact of EMR on midwifery practice and the provision of woman-centred care. We conducted a thematic analysis of semi-structured interviews with 15 midwives across two Australian tertiary public hospitals. Participating midwives cared for women across the pregnancy continuum. Midwives practiced in caseload models of care (3) and core hospital models of care (12). Midwives described a significant increase to the documentation burden since the transition from paper to EMR. An overarching theme of reconciling being with woman while being with computer emerged. Midwives described how their professional identity, embedded in their ability to be intimately present with the labouring woman, conflicted with medico-legal requirements of contemporaneous documentation and practicalities, such as the location of the computers. Midwives negotiated these competing demands to keep the woman at the centre of care. The lack of functionality of the EMR led to workflow inefficiencies, workplace tension and loss of job satisfaction. Midwives are focussed on being ‘with woman’ and providing woman-centred care while at the same time fulfilling their professional obligations of documentation. Midwives are well placed to make recommendations on the functionality of the EMR. Translating these findings to practice and education could lead to system improvements.

Neonatal electronic resuscitation app documentation (NeRD): Electronic documentation compared to written documentation

BackgroundAt present, neonatal resuscitations are documented on the Neonatal Emergence Record, but thorough completion of this record in resuscitations, on average, is poor and less than adequate for proficient, safe and legal documentation. Failure of an accurate representation of a full resuscitation, in real time, can have a bearing on the clinical care given, for example in hypoxic infants. ObjectivesThe objective is to improve documentation of resuscitation, ensuring accurate, contemporaneous and complete documentation of neonatal resuscitation in real time. MethodsA pilot study evaluated the feasibility, time, cost, adverse events and effect size (statistical variability) to predict an appropriate sample size and improve upon the study design prior to the performance of a full-scale study.Twenty neonatal participants were enrolled in the pilot study. The sequence of randomization was computer generated and blinded to each resuscitation team. ConclusionThe NeRD app achieved higher levels of task completion for majority of the audit criteria. Although only a small study the NeRD app allowed for more accurate and contemporaneous documentation when compared to the current paper-based documentation. In a time where litigation is high and all medical and nursing documentation are scrutinized, high quality, accurate, contemporaneous documentation will be of value. Therefore, the main pilot study is feasible without changes to the protocol. A larger randomized controlled trial is needed for more robust evidence in the use of the NeRD app in documenting neonatal resuscitation.

Daily angina documentation versus subsequent recall: development of a symptom smartphone app.

The traditional approach to documenting angina outcomes in clinical trials is to ask the patient to recall their symptoms at the end of a month. With the ubiquitous availability of smartphones and tablets, daily contemporaneous documentation might be possible. The ORBITA-2 symptom smartphone app was developed with a user-centred iterative design and testing cycle involving a focus group of previous ORBITA participants. The feasibility and acceptability were assessed in an internal pilot of participants in the ongoing ORBITA-2 trial. Seven days of app entries by ORBITA-2 participants were compared with subsequent participant recall at the end of the 7-day period. The design focus group tested a prototype app. They reported that the final version captured their symptoms and was easy to use. In the completion assessment group, 141 of 142 (99%) completed the app in full and 47 of 141 (33%) without reminders. In the recall assessment group, 29 of 29 (100%) participants said they could recall the previous day's symptoms, and 82% of them recalled correctly. For 2 days previously, 88% said they could recall and of those, 87% recalled correctly. The proportion saying they could recall their symptoms fell progressively thereafter: 89, 67, 61, 50%, and at 7 days, 55% (P < 0.001 for trend). The proportion of recalling correctly also fell progressively to 55% at 7 days (P = 0.04 for trend). Episode counts of angina are difficult to recall after a few days. For trials such as ORBITA-2 focusing on angina, daily symptom collection via a smartphone app will increase the validity of the results.

Cassius Dio's figures for the demographic consequences of the Bar Kokhba War: Exaggeration or reliable account?

AbstractScholars have long doubted the historical accuracy of Cassius Dio's account of the consequences of the Bar Kokhba War (Roman History 69.14). According to this text, considered the most reliable literary source for the Second Jewish Revolt, the war encompassed all of Judea: the Romans destroyed 985 villages and 50 fortresses, and killed 580,000 rebels. This article reassesses Cassius Dio's figures by drawing on new evidence from excavations and surveys in Judea, Transjordan, and the Galilee. Three research methods are combined: an ethno-archaeological comparison with the settlement picture in the Ottoman Period, comparison with similar settlement studies in the Galilee, and an evaluation of settled sites from the Middle Roman Period (70–136 CE). The study demonstrates the potential contribution of the archaeological record to this issue and supports the view of Cassius Dio's demographic data as a reliable account, which he based on contemporaneous documentation.

Tax Implications of COVID-19 in Singapore

As taxpayers in Singapore deal with a radically changed business environment due to COVID-19, there is a need to make non-routine decisions quickly. These decisions can have significant tax implications, which will likely manifest themselves later as the economy recovers. It is critical for taxpayers to understand the tax consequences of their decisions, even as they focus on issues of immediate survival. While the majority of the relevant tax principles are not new, the COVID-19 pandemic has resulted in the need to apply these existing principles to new situations and increased the frequency of certain activities that may have been uncommon prior to the pandemic. Business decisions undertaken during the COVID-19 pandemic will affect the whole range of taxes, including income tax, goods and services tax, stamp duties and property tax. The importance of understanding the tax consequences of these non-routine decisions and of maintaining contemporaneous documentation cannot be overstated.

Documentation in the patient medical record was associated with improved adherence to Poisons Information Centres telephone advice

Context: There is little research examining clinician adherence to specialist toxicological phone advice. Efforts to improve adherence should be sought to optimise the management of poisoned patients. This study aimed to determine if contemporaneous documentation in the patient electronic medical record (EMR) improved adherence to Poisons Information Centre (PIC) advice.Methods: This was a prospective before and after observational study following the implementation of documented poisoning management advice by PIC staff into the patient’s EMR. Advice adherence was assessed following a review of the patient medical records and designated to complete adherence, minor discrepancies not affecting patient care, major discrepancies affecting patient care and non-adherence. The primary outcome was the proportion of satisfactory (complete adherence/minor discrepancies) adherence. Secondary outcomes included the accuracy of documented telephone advice by the treating clinician, the number of case recalls and episodes of sub-optimal management.Results: A total of 980 cases (347 in the pre-intervention phase and 633 in the post-intervention phase) were included in the study, of which 350 had PIC EMR documentation performed. Documented call advice by the treating clinician was absent in 41 of 347 cases (11.8%) cases and inaccurate in 42 of 306 cases (13.7%). Following PIC documentation, satisfactory adherence improved from 304/347(87.6%) to 333/350(95.1%)(difference 7.5% [95% CI 3.1% to 11.9%]), with suboptimal management decreasing from 48/347(13.8%) to 14/350(4%)(difference − 9.8% [95% CI −5.5% to −14.4%]). Recalls were similar in both periods. The median time to enter advice into the EMR was 26 min (IQR: 14–45 min). The main reason for not documenting advice was that the PIC staff member was working a solo shift with a prohibitively heavy workload.Discussion: EMRs enable PICs to supplement verbal advice with written documentation, offering an opportunity to improve communication and enable better handover of clinical information.Conclusion: Documentation of advice by PIC staff in the patient medical record was associated with improved advice adherence and reduced sub-optimal management.

Pull back the curtain: External data validation is an essential element of quality improvement benchmark reporting.

Accurate and reliable data are pivotal to credible risk-adjusted modeling and hospital benchmarking. Evidence assessing the reliability and accuracy of data elements considered as variables in risk-adjustment modeling and measurement of outcomes is lacking. This deficiency holds the potential to compromise benchmarking integrity. We detail the findings of a longitudinal program to evaluate the impact of external data validation on data validity and reliability for variables utilized in benchmarking of trauma centers. A collaborative quality initiative-based study was conducted of 29 trauma centers from March 2010 through December 2018. Case selection criteria were applied to identify high-yield cases that were likely to challenge data abstractors. There were 127,238 total variables validated (i.e., reabstracted, compared, and reported to trauma centers). Study endpoints included data accuracy (agreement between registry data and contemporaneous documentation) and reliability (consistency of accuracy within and between hospitals). Data accuracy was assessed by mean error rate and type (under capture, inaccurate capture, or over capture). Cohen's kappa estimates were calculated to evaluate reliability. There were 185,120 patients that met the collaborative inclusion criteria. There were 1,243 submissions reabstracted. The initial validation visit demonstrated the highest mean error rate at 6.2% ± 4.7%, and subsequent validation visits demonstrated a statistically significant decrease in error rate compared with the first visit (p < 0.05). The mean hospital error rate within the collaborative steadily improved over time (2010, 8.0%; 2018, 3.2%) compared with the first year (p < 0.05). Reliability of substantial or higher (kappa ≥0.61) was demonstrated in 90% of the 20 comorbid conditions considered in the benchmark risk-adjustment modeling, 39% of these variables exhibited a statistically significant (p < 0.05) interval decrease in error rate from the initial visit. Implementation of an external data validation program is correlated with increased data accuracy and reliability. Improved data reliability both within and between trauma centers improved risk-adjustment model validity and quality improvement program feedback.

Special Document File

A 2019 investigation by the Israeli NGO Akevot and Haaretz newspaper has uncovered official suppression of crucial documents about the Nakba in Israeli archives. The Journal of Palestine Studies is publishing print excerpts and a full online version of the buried “migration report,” which details Israel's depopulation of Palestinian villages in the first six months of the 1948 war, a document that clearly undermines official Israeli state narratives about the course of events. In methodical fashion, this report provides contemporaneous documentation of Israeli culpability in the expulsion of Palestinians from their homes and the systematic depopulation of so-called Arab villages in the first six months of the war. Alongside a discussion of key revelations in the newly available document, this introduction situates the broader pattern of erasure within historiographical debates over 1948 and questions of archival access. It examines how accounts of Israel's birth and Palestinian statelessness have been crafted in relation to the underlying question: who has permission to narrate the past?

A Practical Guide to the Four-Tiered Documentation Approach and Contemporaneous Documentation Requirements in Japan for Foreign Multinationals

As a part of the 2016 tax reform in Japan, the Special Taxation Measures Law (STML) was revised based on the recommendations of the OECD Base Erosion and Profit Shifting (BEPS) Project, and a four-tiered documentation approach was introduced, together with the concept of contemporaneous documentation. Although the rules have been in force for some time, a few of the items have their first submission deadlines in the fiscal year that started or is starting on and after 1 April 2018. The purpose of this article is to broadly describe the four-tiered documentation requirements, clarify the differences between some of the Japanese and the OECD-based requirements, as well as provide practical guidance on the rules to consider for foreign corporations in Japan covered by the documentation submission requirements in articles 66-4-4 and 66-4-5 of the STML or subject to contemporaneous documentation as set out in article 66-4(6) of the STML.

Improving safety and efficacy of the Surgical Ward Round

Introduction and Aims: Comprehensive and contemporaneous documentation of the Consultant led Morning Meeting (MM) and the Surgical Ward Round (SWR) is of paramount importance to improve patient care and patient outcomes. Checklists have shown to improve consistency of patient care. The aim of this audit was therefore to create a checklist to be adopted by the department to be used at the MM and SWR to improve their documentation.

Setting the Record Straight: The Importance of Contemporaneous Documentation and the Proper Use of Post-Protest Documentation to Fill Gaps in the Record for GAO Bid Protests

Setting the Record Straight: The Importance of Contemporaneous Documentation and the Proper Use of Post-Protest Documentation to Fill Gaps in the Record for GAO Bid Protests

Risk Management and the Suicidal Patient

In the management of the suicidal patient, fear of criticism or adverse findings by coroners’ courts can inappropriately influence a clinician's decision-making. The management particularly of the patient with borderline personality disorder, who deliberately self-harms or is suicidal, is made more challenging by the negative transference these patients may evoke.Adherence to evidence-based practice – excluding comorbid or differential diagnoses, crisis management, judicious hospital admissions, targeted medication and appropriate outpatient therapies – as well as detailed contemporaneous documentation of the decision-making are the mainstays of risk management of the patient with borderline personality disorder. The management plan should be informed by cross-sectional risk assessments and serial risk-benefit analyses. After providing illness education, the scenario planning and crisis intervention plan should be agreed with the patient and the patient's family and supports. Maintaining continuing professional development and peer review will also best approximate the “peer professional opinion” which is mandated by the various Civil Liability Act provisions in all Australian jurisdictions.

Medicolegal pitfalls of cataract surgery

To provide a general overview of medicolegal issues that may arise before, during, and after cataract surgery. The Department of Health and Human Services Office of Inspector General has designated ophthalmology as an auditing target, an unusual step to take for an entire specialty. Ongoing False Claims Act litigation may provide greater clarity on billing Medicare for a premium intraocular lens patient's return to the operating room and charging for an intervening exam when performing cataract surgery on both eyes. Ophthalmologists should continue to follow basic principles that help decrease medicolegal risk. These include a thorough informed consent discussion before surgery and accurate and contemporaneous documentation. When complications arise, surgeons should handle them in accordance with best practices and refer patients appropriately. Problems can arise from inattentive postoperative care, so ophthalmologists should train staff members on handling of patient calls. Implementing safety protocols for intraocular lens implantation and asking for legal advice when considering certain types of financial arrangements are also prudent. Cataract surgeons also should follow guidelines for billing noncovered services carefully.

A nine-year review of medicolegal claims in neurosurgery.

Neurosurgery remains among the highest malpractice risk specialties. This study aimed to identify areas in neurosurgery associated with litigation, attendant causes and costs. Retrospective analysis was conducted of 42 closed litigation cases treated by neurosurgeons at one hospital between March 2004 and March 2013. Data included clinical event, timing and reason for claim, operative course and legal outcome. Twenty-nine claims were defended out of court and twelve were settled out of court. One case required court attendance and was defended. Of the 42 claims, 28, 13 and 1 related to spinal (0.3% of caseload), cranial (0.1% of caseload) and peripheral nerve (0.07% of caseload) surgery respectively. The most common causes of claims were faulty surgical technique (43%), delayed diagnosis/misdiagnosis (17%), lack of information (14%) and delayed treatment (12%), with a likelihood of success of 39%, 29%, 17% and 20% respectively. The highest median payouts were for claims against faulty surgical technique (£230,000) and delayed diagnosis/misdiagnosis (£212,650). The mean delay between clinical event and claim was 664 days. Spinal surgery carries the highest litigation risk versus cranial and peripheral nerve surgery. Claims are most commonly against faulty surgical technique and delayed diagnosis/misdiagnosis, which have the highest success rates and payouts. In spinal surgery, the most common cause of claims is faulty surgical technique. In cranial surgery, the most common cause is lack of information. Claims may occur years after the clinical event, necessitating thorough contemporaneous documentation for adequate future defence. We emphasise thorough patient consultation and meticulous surgical technique to minimise litigation in neurosurgical practice.

The Landmark Decision in Jockey Canada Company v. President of Canada Border Services Agency: Lessons for Compliance with Canadian Customs Valuation Requirements

This paper analyses the reasons for the Canadian International Trade Tribunal's decision in Jockey Canada Company v. President of Canada Border Services Agency respecting Canadian customs valuation compliance in related party cross-border transactions. It offers practical insights into the precautions that should be taken by multinational companies when structuring import transactions in order to satisfy their evidentiary burden to prove the accuracy of declared values for duty, including the maintenance of probative supporting documentary evidence and the need for customs valuation oriented contemporaneous documentation such as granular transfer pricing studies and agreements between related parties that discretely cover intercompany payments. The application of the transaction value method when pricing is based on a formulaic transfer pricing policy is also examined.

Transfer Pricing Documentation for Business Restructurings

This article deals with the challenge of documenting business restructurings for transfer pricing purposes. It links the discussion to the ongoing debate of risk management for transfer pricing, and suggests how MNEs can build a business case for change and sufficiently evidence the operational transformation by following an efficient, contemporaneous documentation approach.

PL.31 A Simple Classification System for Maternal Traumatic Injuries Associated with Second Stage Caesarean Section

Background Caesarean section at full dilatation can be a technically demanding procedure and has a consistent association with laceration injuries to uterus, cervix and vagina. Recent Scottish Morbidity data showed...

The Egyptian Royal Titulary of Alexander the Great, I: Horus, Two Ladies, Golden Horus, and Throne Names*

This is the first of a two-part study of the pharaonic titulary of Alexander the Great. Analysing all available contemporaneous documentation, including onomastic data newly published, the king's names are presented, with particular attention to variants. The parallels and symbolic meaning of each name are discussed, as are the legitimating strategies that lay behind their selection. The present paper deals with the first four names of the royal protocol.

A Systematic Review of the Prevalence of Signs of Impending Death and Symptoms in the Last 2 Weeks of Life

To optimally manage patient care, knowledge of the prevalence of signs of impending death and common symptoms in the last days is needed. Two reviewers independently conducted searches of PubMed, CINAHL, PsychINFO and the Web of Knowledge from January, 1996 to May, 2012. No limits to publication language or patient diagnosis were imposed. Peer reviewed studies of adults that included contemporaneous documentation of signs and symptoms were included. Articles were excluded if they assessed symptoms by proxy or did not provide information on prevalence. Reviewers independently extracted data. Twelve articles, representing 2416 patients, in multiple settings were analyzed. Of the 43 unique symptoms, those with the highest prevalence were: dyspnea (56.7%), pain (52.4%), respiratory secretions/death rattle (51.4%), and confusion (50.1%). Overall prevalence may be useful in anticipating symptoms in the final days and in preparing families for signs of impending death.