Discrepancies In Documentation Research Articles

Analysing Health Professionals' Adherence to National Guidelines and Comparing Diabetes Care in Specialized Care Centres and Hospitals

The socioeconomic impact of diabetes treatment includes significant costs for diagnosis, treatments, hospitalizations, and associated social challenges. According to the International diabetic federation (IDF) guidelines, effective management entails a holistic strategy including nutritious diet, avoiding carbonated beverages, quitting smoking, and routine exercising. Targeted weight loss is critical, comprising antidiabetic medications, a specific food plan, and lifestyle changes to attain a 7-8% glycated hemoglobin level. Proper medicine and footwear use reduces ulcer risks and further complications. The IDF emphasizes detailed treatment plans and sequential screenings. Diabetes management is obligatory, focusing glycaemic control, lifestyle changes, and risk assessment. A study examines treatment programs, medical behaviour, and factors impacting diabetic care reception. This study examined diabetes mellitus treatment in medical facilities by conducting health information reviews in outpatient clinics with a sample size of 400 records. Java applets detected problems, indicating 95% confidence in therapy. Cross-sectional studies in Peshawar hospitals included 250 patients, whereas specialized diabetic treatment centers evaluated 150 patients. Documented care differed; public hospitals had lower foot inspection rates (16.4%) than specialized care (14%). Statistical analysis, such as the Chung test and binary logistic regression, was used to assess variable relationships. Smoking was common (86%), and 59.8% relied on oral anti-diabetic medications. Less than 30% follow up examinations were recorded in public hospitals which showed discrepancies in documentation. Diabetes management can be improved, particularly through better screening procedures. Discrepancies between provided and documented care underscore the need for higher documentation standards. Private clinics demonstrated comparatively better care, possibly influenced by consultation fees, facility availability, and a comfortable environment—attributes lacking in public hospitals in Pakistan.

Reconciling Allergy Information in the Electronic Health Record After a Drug Challenge Using Natural Language Processing.

BackgroundDrug challenge tests serve to evaluate whether a patient is allergic to a medication. However, the allergy list in the electronic health record (EHR) is not consistently updated to reflect the results of the challenge, affecting clinicians' prescription decisions and contributing to inaccurate allergy labels, inappropriate drug-allergy alerts, and potentially ineffective, more toxic, and/or costly care. In this study, we used natural language processing (NLP) to automatically detect discrepancies between the EHR allergy list and drug challenge test results and to inform the clinical recommendations provided in a real-time allergy reconciliation module.MethodsThis study included patients who received drug challenge tests at the Mass General Brigham (MGB) Healthcare System between June 9, 2015 and January 5, 2022. At MGB, drug challenge tests are performed in allergy/immunology encounters with routine clinical documentation in notes and flowsheets. We developed a rule-based NLP tool to analyze and interpret the challenge test results. We compared these results against EHR allergy lists to detect potential discrepancies in allergy documentation and form a recommendation for reconciliation if a discrepancy was identified. To evaluate the capability of our tool in identifying discrepancies, we calculated the percentage of challenge test results that were not updated and the precision of the NLP algorithm for 200 randomly sampled encounters.ResultsAmong 200 samples from 5,312 drug challenge tests, 59% challenged penicillin reactivity and 99% were negative. 42.0%, 61.5%, and 76.0% of the results were confirmed by flowsheets, NLP, or both, respectively. The precision of the NLP algorithm was 96.1%. Seven percent of patient allergy lists were not updated based on drug challenge test results. Flowsheets alone were used to identify 2.0% of these discrepancies, and NLP alone detected 5.0% of these discrepancies. Because challenge test results can be recorded in both flowsheets and clinical notes, the combined use of NLP and flowsheets can reliably detect 5.5% of discrepancies.ConclusionThis NLP-based tool may be able to advance global delabeling efforts and the effectiveness of drug allergy assessments. In the real-time EHR environment, it can be used to examine patient allergy lists and identify drug allergy label discrepancies, mitigating patient risks.

Reporting and Abstracting Variability in Technical Standards for Breast Cancer Operations

BackgroundThe American College of Surgeons Commission on Cancer has incorporated documentation of critical elements outlined in Operative Standards for Cancer Surgery into revised standards for cancer center accreditation. This study assessed the current documentation of critical elements in partial mastectomy (PM) and sentinel lymph node biopsy (SLNB) operative reports. Materials and methodsOperative reports for PM + SLNB at a single academic institution from 2013 to 2018 were reviewed for compliance and surveyor interobserver reliability with the Oncologic Elements of Operative Record defined in Operative Standards and compared with a nonredundant American Society of Breast Surgeons Mastery of Breast Surgery (MBS) quality measure for specimen orientation. ResultsTen reviewers each evaluated 66 PM + SLNB operative reports for 13 Oncologic Elements and one MBS measure. No operative records reported all critical elements for PM + SLNB or PM alone. Residents completed 36.4% of operative reports: Element documentation was similar for PM but varied significantly for SLNB between resident and attending authorship. Combined reporting performance and interrater reliability varied across all elements and was highest for the use of SLNB tracer (97.1% and κ = 0.95, respectively) and lowest for intraoperative assessment of SLNB (30.6%, κ = 0.43). MBS specimen orientation had both high proportion reported (87.0%) and interrater reliability (κ = 0.84). ConclusionsAdherence to reporting critical elements for PM and SLNB varied. Whether differential compliance was tied to discrepancies in documentation or reviewer abstraction, clarification of synoptic choices may improve reporting consistency. Evolving techniques or technologies will require continuous appraisal of mandated reporting for breast surgery.

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients.

Background Depression is substantially underdiagnosed in primary care, despite recommendations for screening at every visit. We report a secondary analysis focused on depression of a recently completed study using unannounced standardized patients (USPs) to measure and improve provider behaviors, documentation, and subsequent claims for real patients. Methods Unannounced standardized patients presented incognito in 217 visits to 59 primary care providers in 22 New Jersey practices. We collected USP checklists, visit audio recordings, and provider notes after visits; provided feedback to practices and providers based on the first two visits per provider; and compared care and documentation behaviors in the visits before and after feedback. We obtained real patient claims from the study practices and a matched comparison group and compared the likelihood of visits including International Classification of Diseases, 10th Revision (ICD-10) codes for depression before and after feedback between the study and comparison groups. Results Providers significantly improved in their rate of depression screening following feedback [adjusted odds ratio (AOR), 3.41; 95% confidence interval (CI), 1.52-7.65; p = 0.003]. Sometimes expected behaviors were documented when not performed. The proportion of claims by actual patients with depression-related ICD-10 codes increased significantly more from prefeedback to postfeedback in the study group than in matched control group (interaction AOR, 1.41; 95% CI, 1.32-1.50; p < 0.001). Conclusions Using USPs, we found significant performance issues in diagnosis of depression, as well as discrepancies in documentation that may reduce future diagnostic accuracy. Providing feedback based on a small number of USP encounters led to some improvements in clinical performance observed both directly and indirectly via claims.

Medication Allergy and Adverse Drug Reaction Documentation Discrepancies in an Urban, Academic Emergency Department.

Medication histories, including knowledge of allergies and adverse drug reactions (ADRs), are a nationally recognized quality measure. Medication histories in the emergency department (ED) are often inaccurate or incomplete. Our objective was to determine the prevalence and nature of medication allergy and ADR discrepancies in an urban ED. This was a prospective observational descriptive study, enrolling a convenience sample of adults over 7months at a single academic urban ED. Trained personnel recorded patient demographics and number of daily medications. Patients listed any prior drug allergies or non-allergic ADRs. Following the ED encounter, the patients' self-reported allergies and ADRs were compared to the electronic medical record (EMR) to identify and describe discrepancies. A sample of 1014 patients, predominantly black (81%), female (60%), and in the 18- to 59-year-old range (69%), was recruited. Most patients were taking at least one daily medication (74%). Three hundred fifteen patients reported at least one allergy (31%), and 252 (25%) at least one ADR. Four hundred sixteen patients (41%) had a discrepancy between their self-report of allergy or ADR and the EMR. Omissions were the most frequent discrepancy. Full descriptions of allergies or ADR were present in 18.4% of charts. Fifty-seven patients (5.6%) were administered a medication which could have interacted with a documented allergy or ADR; none of the allergy EMR records were updated to reflected this. In this cross-sectional ED study, drug allergies and ADRs were both highly prevalent. There were significant discrepancies in documentation of allergies and ADRs between patient self-report and the EMR.

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes

BackgroundLittle is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.MethodsThis was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.ResultsA total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9–2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31–53%]. Qualitative analyses identified eight themes related to focus (central point – e.g., problem list), structure (organization, – e.g., note-taking style), and purpose (intention – e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.ConclusionsImportant gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.

Exploring the Northern Sotho language name discrepancies in informative documentation and among first language speakers

This article is based on a survey that aimed to explore the Northern Sotho language name discrepancies in informative and descriptive documentation and also in general language use. The survey was conducted in two selected South African universities (Tshwane University of Technology (A) and the University of Limpopo (B)). The quota sampling method was used to gather data from 90 students and ten lecturers who were then doing Northern Sotho as a first-language module or teaching any of these modules, their age groups varying from 17 to 75. These students and lecturers participated by responding to survey questionnaires and the lecturers additionally took part in interviews. The causes for the use of Sepedi and Sesotho sa Leboa in informative documentation and in general language, as well as the language name which was preferred by the research participants were investigated, based on the mixed-methods research approach. From a sociolinguistic perspective, the survey strove to ascertain which of the two language names the research participants preferred and why. It was found that Sesotho sa Leboa was the name opted for by most of the research participants who considered Sepedi as a dialect, not as a standard language.

Evaluation of the Type and Frequency of Errors Discovered During Routine Secondary Patient Chart Review

Purpose: Desire to improve efficiency and throughput inspired a review of the frequency and scope of our physics chart check procedures. Departmental policy mandates review of a patient’s treatment plan prior to port-filming, after first treatment and “weekly” every 3-5 fractions. This study examined the effectiveness of the “after-first” physics check with respect to improving patient safety and clinical efficiency.Methods and Materials: A shared spreadsheet was created to record errors discovered during patient-specific chart review following the first fraction of treatment and before the second fraction. First, entries were recorded and categorized from August 2014 through February 2015. Frequencies were assessed month-to-month. Next, utilizing thes e results, a continuous quality improvement (CQI) process following Deming’s Plan-Do-Study-Act (PDSA) methodology was generated. The first iteration of this PDSA was adding a dose tracking checklist item in the pre-treatment plan check assessment. A two-sided Fisher’s exact test was used to determine if there was a nonrandom association between the checklist implementation and incidence of dose tracking errors.Results: Analysis of recorded errors indicated an overall error rate of 3.4% over the 13 month period. The majority of errors related to discrepancies in documentation, followed by prescription, plan deficiency, and dose tracking-related errors. A two-sided Fisher’s exact test revealed a statistically significant decrease in dose tracking-related errors after implementing the checklist item (p = 0.0322, significance level = 0.05). Conclusions: This work indicates that this redundant secondary check is an effective QA process in our department. The first month spike in rates could be due to the Hawthorne/observer effect, but the consistent 3% error rate suggests the need for continuous quality improvement and periodical re-training on errors noted as frequent to improve awareness and quality of the initial chart review process, which may lead to improved treatment quality, patient safety and increased clinical efficiency.

Discrepancies in Communication Versus Documentation of Weight-Management Benchmarks: Analysis of Recorded Visits With Latino Children and Associated Health-Record Documentation.

To examine gaps in communication versus documentation of weight-management clinical practices, communication was recorded during primary care visits with 6- to 12-year-old overweight/obese Latino children. Communication/documentation content was coded by 3 reviewers using communication transcripts and health-record documentation. Discrepancies in communication/documentation content codes were resolved through consensus. Bivariate/multivariable analyses examined factors associated with discrepancies in benchmark communication/documentation. Benchmarks were neither communicated nor documented in up to 42% of visits, and communicated but not documented or documented but not communicated in up to 20% of visits. Lowest benchmark performance rates were for laboratory studies (35%) and nutrition/weight-management referrals (42%). In multivariable analysis, overweight (vs obesity) was associated with 1.6 more discrepancies in communication versus documentation (P = .03). Many weight-management benchmarks are not met, not documented, or performed without being communicated. Enhanced communication with families and documentation in health records may promote lifestyle changes in overweight children and higher quality care for overweight children in primary care.

Discrepancies in Race and Ethnicity Documentation: a Potential Barrier in Identifying Racial and Ethnic Disparities

BackgroundData collection on race and ethnicity is critical in the assessment of racial disparities related to health. Studies comparing clinical and administrative data show discrepancies in race documentation and attribution.MethodsSelf-reported data from two studies were compared to demographics in the electronic health record (EHR) extracted from the Biomedical Translational Research Information System (BTRIS) repository. McNemar and Bhapkar analyses were conducted to quantify the agreement of ethnicity and race between self-reported and EHR data. Pearson’s chi-square tests were used to explore the relationship between acculturation, length of time in the USA, country of residence, and how individuals self-reported their race.ResultsThe sample (n = 280) was predominantly female (52.1 %), with a mean age of 47 (SD ± 13.74), mean years in the USA were 12.8 (SD ± 11.67) and the majority were born outside of the USA. (55.6 %). Those who self-identified as Hispanic (n = 208) scored a mean of 5.5 (SD ± 3.07) on the short acculturation scale (SAS) that ranges 4 to 20; lower scores indicate less acculturation. A significant difference was found between the way race is reported in the electronic medical record and self-reported data among those people who identified as Hispanic, with significant differences in the white (p < 0.0001) and other (p < 0.0001) categories.ConclusionsThe misclassification of race is most frequent in those individuals who self-identified as Hispanic. As the Hispanic population in the USA continues to grow, understanding the factors that affect the way that individuals from this heterogeneous population self-report race may provide important guidance in tailoring care to address health disparities.

Accuracy of Adverse Drug Reaction Documentation upon Implementation of an Ambulatory Electronic Health Record System.

BackgroundDetection, monitoring and treatment of adverse drug reactions (ADRs) are paramount to patient safety. The use of a comprehensive electronic health record (EHR) system has the potential to address inadequacies in ADR documentation and to facilitate ADR reporting to health agencies. However, effective methods to maintain the quality of documented ADRs within an EHR have not been well studied.ObjectiveTo evaluate the accuracy and effectiveness of ADR documentation transfer throughout the implementation of a comprehensive EHR system.MethodsRetrospective analysis of ADR documentation at a tertiary care pediatric hospital between January 2013 and June 2014. ADRs documented in the newly implemented ambulatory EHR, pharmacy system and hybrid health record system were extracted. Documentation inconsistencies and processes for managing ADR documentation within the EHR were reviewed.ResultsA total of 115 patients with 260 unique ADRs were identified. Only 155 (60 %) of the identified ADRs were found in the ambulatory EHR system. The remaining 105 ADRs (40 %) were missing from the EHR when it was compared with the other systems. Seventy-two patients (63 %) returned for a follow-up visit, and each had their ADR documentation reviewed in the ambulatory EHR. Following the visit, 44 % of these ambulatory EHR records still included incorrect information.ConclusionsWe identified discrepancies in ADR documentation within hospital systems, which need to be addressed as healthcare institutions transition to EHRs. Processes related to the transfer of ADR information into the EHR should be clearly defined. To improve the quality of ADR documentation, steps to force complete and continual ADR verification should be introduced at early stages of implementation of a new EHR, and all responsible providers should play a role.Electronic supplementary materialThe online version of this article (doi:10.1007/s40801-016-0071-8) contains supplementary material, which is available to authorized users.

SU‐E‐T‐408: Evaluation of the Type and Frequency of Variations Discovered During Routine Secondary Patient Chart Review

Purpose:Desire to improve efficiency and throughput inspired a review of our physics chart check procedures. Departmental policy mandates plan checks pre‐treatment, after first treatment and weekly every 3–5 days. This study examined the effectiveness of the “after first” check with respect to improving patient safety and clinical efficiency. Type and frequency of variations discovered during this redundant secondary review was examined over seven months.Methods:A community spreadsheet was created to record variations in care discovered during chart review following the first fraction of treatment and before the second fraction (each plan reviewed prior to treatment). Entries were recorded from August 2014 through February 2015, amounting to 43 recorded variations out of 906 reviewed charts. The variations were divided into categories and frequencies were assessed month‐to‐month.Results:Analysis of recorded variations indicates an overall variation rate of 4.7%. The initial rate was 13.5%; months 2–7 average 3.7%. The majority of variations related to discrepancies in documentation at 46.5%, followed by prescription, plan deficiency, and dose tracking related variations at 25.5%, 12.8%, and 12.8%, respectively. Minor variations (negligible consequence on patient treatment) outweighed major variations 3 to 1.Conclusion:This work indicates that this redundant secondary check is effective. The first month spike in rates could be due to the Hawthorne/observer effect, but the consistent 4% variation rate suggests the need for periodical re‐training on variations noted as frequent to improve awareness and quality of the initial chart review process, which may lead to improved treatment quality, patient safety and increased clinical efficiency. Utilizing these results, a continuous quality improvement process following Deming's Plan‐Do‐Study‐Act (PDSA) methodology was generated. The first iteration of this PDSA was adding a specific dose tracking checklist item in the pre‐treatment plan check assessment; the ramification of which will be assessed in future data.

Special requirements for electronic medical records in neurology.

Electronic medical records (EMRs) are being rapidly adapted in the United States with goals of improving patient care, increasing efficiency, and reducing costs. Neurologists must become knowledgeable about the utility and effectiveness of the important parts of these systems specifically needed for care of neurology patients. The field of neurology encompasses complex disorders whose diagnosis and management heavily relies on detailed medical documentation of history and physical examination, and often on specialty-specific ancillary tests and extensive neuroimaging. Small discrepancies in documentation or absence of an in-hand ancillary test result can drastically change the current workup or treatment decision of a complex patient with neurologic disease. We describe current models and opportunities for improvements to EMRs that provide utility and efficiency in the care of neurology patients.

Confidentiality protections versus collaborative care in the treatment of substance use disorders.

Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients’ primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.

ApoLänk decreases patient medication discrepancies at discharge: initial experience from a Swedish bedside pharmacy service

ObjectiveTo develop a working model so that dispensing pharmacists, patients and medical staff can work together to identify, solve and prevent problems associated with discharge prescriptions.MethodsA routine was developed for...

Spina bifida: A diagnostic dilemma in paleopathology

This article provides information regarding the etiology, pathogenesis, and skeletal manifestation of spina bifida or spinal dysraphisms. On the basis of a review of the medical literature, it addresses discrepancies in documentation and interpretation of spina bifida in paleopathology. Furthermore, it offers suggestions for use of universal terminology and highlights the difficulties in the specific diagnosis of dysraphisms in skeletal remains. In addition, the necessity of examining the entire skeleton for abnormalities to distinguish simple delay/failure of fusion of the posterior neural arches from other occult spinal dysraphisms is emphasized, as it is the need for stratification of the sample by age and sex when reporting frequencies of sacral spina bifida occulta.

Using Consumer-Based Kiosk Technology to Improve and Standardize Medication Reconciliation in a Specialty Care Setting

Discrepancies in medication documentation most often occur at handoffs or transition points in care. A process improvement team at the Portland Department of Veterans Affairs developed a standardized medication reconciliation process for the Portland chemotherapy administration unit, a physically self-contained clinic with a standard intake process and a uniform patient traffic pattern. The team developed the automated patient history intake device (APHID), a reconciliation software program accessed by the patient using a computer terminal kiosk in the clinic lobby. The program simultaneously checks in patients for an appointment and gathers a medication-adherence history by retrieving medication lists from all Veterans Affairs facilities and pairing each medication with a pill picture. Installation of the APHID kiosk included an initial two-week roll-in period beginning in February 2008. During the roll-in period, 91 (82.0%) of 111 patients completed check-in and performed medication reconciliation using the kiosk. Medication lists gathered at the kiosk were compared with existing health record documentation and clinician interviews. For each patient encounter, the process demonstrated an average of 4.59 discrepancies and an average of 1.61 clinically significant or potentially lethal discrepancies. The new process saved approximately 0.24 full-time equivalents of nursing time in the chemotherapy clinic-a nearly 50% reduction in nursing time dedicated to reconciliation activities without an apparent loss in data accuracy. A patient-centered reconciliation model using consumer-based kiosk technology helped providers efficiently retrieve a comprehensive list of medications across a geographically diverse area and improve patient medication recall using visual cues including medication pictures.

Neoetropus macrops Hildebrand and Schroeder, 1928: A Reversed Specimen and a Junior Synonym of Citharichthys arctifrons Goode, 1880 (Teleostei; Pleuronectiformes; Paralichthyidae)

Neoetropus macrops Hildebrand and Schroeder, 1928, a nominal genus and species of dextral flounder known uniquely from the holotype, has been problematic regarding its identity and taxonomic status since its description. Previous treatments considered this dextral flatfish as a possible member of the dextral flounder family Poecilopsettidae or suggested it as a reversed individual of a sinistral paralichthyid species (either Etropus microstomus or Citharichthys arctifrons). However, its identity and status have never been confidently resolved. Following detailed examination of the holotype of N. macrops and comparison with other taxa, the identity and status of this species is resolved. Except for features determined to be anomalous in this specimen (dextral symmetry and short, ocular-side upper jaw), counts, measurements, and other morphological characters (e.g, arrangement of pelvic fins, position of urogenital papilla, and pattern of caudal skeleton ossification) of N. macrops agree with those of Citharichthys arctifrons Goode, 1880. Thus, N. macrops is identified as a reversed individual of the sinistral C. arctifrons. Accordingly, based on this finding, Neoetropus is relegated to the synonymy of Citharichthys Bleeker, 1862, and N. macrops becomes a junior synonym of C. arctifrons Goode, 1880. The reported capture location for this specimen (off the mouth of the Potomac River in Chesapeake Bay) is suspect because of its extremely unusual occurrence for C. arctifrons and discrepancies in documentation associated with this specimen.