Medical Record Documentation Research Articles

The Performance of Electronic Consultation in Non-Malignant Hematology in a Fee-for-Service Care Delivery Model

Background: Electronic consultation (e-consultation) refers to asynchronous electronic communication between a consulting provider and a consulted specialist. Recommendations are formulated by medical record review and communicated via medical record documentation without direct contact between the specialist and patient. There is a current shortage of non-malignant hematologists and hence a need to optimize the efforts of the existing workforce. E-consultation holds promise by allowing simpler consults to be answered quickly, reserving face-to-face (FTF) encounters for complex hematologic questions and therefore allowing hematologists to serve a larger number of patients. Additional benefits of e-consultation include faster response to consultation questions and decreased travel burden for patients. However, due to lower financial incentives for e-consultation compared to FTF in fee-for-service reimbursement models, adoption has been limited. Here, we report the experience with e-consultation in non-malignant hematology in a fee-for-service model at a large academic medical center and compare that experience to published reports in three medical centers with non-fee-for-service models. Methods: On March 1, 2021, the outpatient clinic of the University of Alabama at Birmingham (UAB), implemented e-consultation for non-malignant hematology. E-consults could be initiated by any provider within the UAB system through electronic order entry. Three non-malignant hematologists reviewed and responded to all e-consults and these hematologists, along with an advanced practice provider, conducted all FTF encounters. Retrospective analysis of e-consultation practices, 1 year after implementation was performed. Variables collected included the reason for consultation, date and time of response, the time between e-consult and response, time to review and respond, frequency of conversion to an FTF encounter, and follow-up communication. Results: Over the 1-year study period, 214 e-consults were requested, of which 183 (86%) had an e-consult completed and 31 (14%) were converted to an FTF encounter due to complexity. The frequency of e-consults ordered and completed (i.e., not converted to an FTF encounter) by month is presented in Figure 1. The most common diagnoses prompting consultation included anemia (21%), thrombosis (19%), leukopenia (12%), and thrombocytopenia (11%). There was more than one diagnostic question in 29 e-consults (14%). The average time to review and respond to an e-consult was 8.6 minutes (range 2-20 minutes). The median time from the e-consult request to completion was 2 hours and 34 minutes (IQR 9 hours and 46 minutes). Additional workup, including laboratory testing and/or imaging, was recommended in 56% of e-consults and was performed by the consulting provider. Subsequent communication between the consulting provider and non-malignant hematology provider within 30 days of the e-consult was required in 13% of e-consults. The total number of FTF new patient encounters scheduled in the study year increased to 2,642/year from 1,708/year in the year before e-consult implementation. The average wait time for a physician FTF new patient appointment also increased from 56 days to 88 days. Table 1 presents a comparison of the performance of reported e-consultation systems in non-malignant hematology. Low cell counts (anemia, thrombocytopenia, and leukopenia) were the most common reason for consultation in all systems. Our e-consult system demonstrated a shorter time to complete the consult and a shorter time to respond. A consistent percentage (14-17%) of e-consults were converted to FTF encounters. In the two programs that measured influence on consult volume, both reported a similar increase in total consult volume after e-consult implementation. Conclusions: In a large fee-for-service medical center, the implementation of e-consultation for non-malignant hematologic care did not decrease consult volume, and consulting provider uptake was low. However, when used, e-consultation facilitated rapid delivery of non-malignant hematologic expertise and performed similarly to reported experiences in non-fee-for-service models. Further investigation is needed to determine how e-consultation can be best utilized to maximize access to expertise in non-malignant hematology. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Pilot Intervention to Improve Medication Adherence Among Patients With Systemic Lupus Erythematosus Using Pharmacy Refill Data.

Despite high rates of medication nonadherence among patients with systemic lupus erythematosus (SLE), effective interventions to improve adherence in SLE are limited. We aimed to assess the feasibility of a pilot intervention and explore its effect on adherence. The intervention used pharmacy refill data to monitor nonadherence and prompt discussions surrounding SLE medications during clinic encounters. Over 12 weeks, the intervention was delivered through routine clinic visits by providers to patients with SLE who take SLE-specific medications. We measured acceptability, appropriateness, and feasibility using provider surveys. We also measured acceptability by patient surveys and feasibility by medical record documentation. We explored change in adherence by comparing percent of patients with medication possession ratio (MPR) ≥80% 3 months before and after the intervention visit using the McNemar's test. Six rheumatologists participated; 130 patients were included in the analysis (median age 43, 95% female, and 59% racial and ethnic minorities). Implementation of the intervention was documented in 89% of clinic notes. Provider surveys showed high scores for feasibility (4.7/5), acceptability (4.4/5), and appropriateness (4.6/5). Among patient surveys, the most common reactions to the intervention visit were feeling determined (32%), empowered (32%), and proud (19%). Proportion of patients with MPR ≥80% increased from 48% to 58% (P=0.03) after the intervention visit. Our intervention showed feasibility, acceptability, and appropriateness and led to a statistically significant improvement in adherence. Future work should refine the intervention, assess its efficacy in a controlled setting, and adapt its use among other clinic settings.

A multidisciplinary pediatric oncofertility team improves fertility preservation and counseling across 7 years.

Oncofertility is a developing field of increasing importance, particularly in pediatric oncology, where most patients are likely to survive long-term and have not yet had the opportunity to have children. We performed a quality improvement initiative to increase our rates of fertility preservation counseling and referral through the implementation of a pediatric oncofertility team, and we report outcomes 7 years following implementation of our initiative. We compare our baseline oncofertility survey to 44 post-intervention survey respondents and electronic medical record documentation for 149 patients treated in 2019. Ninety-five percent of post-intervention survey respondents recalled fertility counseling (baseline 70%, p= .004) and 89.3% were appropriately referred for fertility preservation (baseline 50%, p= .017). Counseling was documented in 60.4% of charts; 81% of patients analyzed by chart review were appropriately referred for fertility preservation. Fertility preservation outcomes differed by sex assigned at birth. Creation of an oncofertility team produced improvements in fertility counseling and fertility preservation referral across an extended period of time.

Agreement Between Pregnant Individuals' Self-Report of Coronavirus Disease 2019 (COVID-19) Vaccination and Medical Record Documentation.

For public health research such as vaccine uptake or effectiveness assessments, self-reported coronavirus disease 2019 (COVID-19) vaccination status may be a more efficient measure than verifying vaccination status from medical records if agreement between sources is high. We assessed agreement between self-reported and medical record-documented COVID-19 vaccination status among pregnant individuals followed in a cohort during August 2020-October 2021. At end of pregnancy, participants completed questionnaires about COVID-19 vaccine receipt during pregnancy; staff verified vaccination status using medical records. Agreement was assessed between self-reported and medical record vaccination status using Cohen's kappa. There was high agreement between self-reported and medical record vaccination status (Kappa coefficient=0.94, 95% CI 0.91-0.98), suggesting that self-report may be acceptable for ascertaining COVID-19 vaccination status during pregnancy.

Collaborative to Increase Lethal Means Counseling for Caregivers of Youth With Suicidality.

The number of youth presenting to hospitals with suicidality and/or self-harm has increased substantially in recent years. We implemented a multihospital quality improvement (QI) collaborative from February 1, 2018 to January 31, 2019, aiming for an absolute increase in hospitals' mean rate of caregiver lethal means counseling (LMC) of 10 percentage points (from a baseline mean performance of 68% to 78%) by the end of the collaborative, and to evaluate the effectiveness of the collaborative on LMC, adjusting for secular trends. This 8 hospital collaborative used a structured process of alternating learning sessions and action periods to improve LMC across hospitals. Electronic medical record documentation of caregiver LMC was evaluated during 3 phases: precollaborative, active QI collaborative, and postcollaborative. We used statistical process control to evaluate changes in LMC monthly. Following collaborative completion, interrupted time series analyses were used to evaluate changes in the level and trend and slope of LMC, adjusting for covariates. In the study, 4208 children and adolescents were included-1314 (31.2%) precollaborative, 1335 (31.7%) during the active QI collaborative, and 1559 (37.0%) postcollaborative. Statistical process control analyses demonstrated that LMC increased from a hospital-level mean of 68% precollaborative to 75% (February 2018) and then 86% (October 2018) during the collaborative. In interrupted time series analyses, there were no significant differences in LMC during and following the collaborative beyond those expected based on pre-collaborative trends. LMC increased during the collaborative, but the increase did not exceed expected trends. Interventions developed by participating hospitals may be beneficial to others aiming to improve LMC for caregivers of hospitalized youth with suicidality.

A Mixed Methods Multicenter Study on the Capabilities, Barriers, and Opportunities for Diabetes Screening and Management in the Public Health System of Southern Ethiopia.

More than half of diabetics' in Ethiopia live undiagnosed, and the majority of those who already knew their status also struggle to manage their diseases. However, the underlying challenges are less understood in the study area. Therefore, this study aimed to assess diabetes screening and management capabilities, barriers, and opportunities in southern Ethiopia. We applied a mixed methods study. To assess the healthcare systems' capabilities, we collected quantitative data from randomly selected ten hierarchically organized healthcare facilities, and purposive maximum variation sampling was applied to recruit twenty-nine individuals for face-to-face in-depth interviewing. The interviews were audio recorded, transcribed verbatim, thematically analyzed, and presented accordingly. Our study findings indicated that there were good opportunities and encouraging capabilities like government commitment and expansion of services to improve diabetes screening and management in southern Ethiopia. Nevertheless, poor governance, the system's structural problems, skilled professionals' inaccessibility and lack of teamwork, poor service integration, poor planning, and lack of monitoring and evaluation mechanisms have been hampering the service delivery at the system level. While service unaffordability, low awareness level, and lifestyle modification problems were the main challenges at the patient level. Furthermore, outdated paper-based medical record documentation, frequent essential drug stock-outing, essential laboratory service interruptions, and none-use of some available services like HbA1c have been contributing to the barriers. Despite favorable capabilities available, diabetes management in southern Ethiopia has been struggling with solvable structural defects, poor service delivery and inaccessibility, and patients' poor lifestyle modification. Therefore, public health system restructuring, optimum financing, computerization of medical records documentation, and health system and patient capacity building are strongly recommended interventions to tackle the problem at the grass-root level.

The Effect of Pharmacy-Led Medication Reconciliation on Odds of Psychiatric Relapse at a Community Hospital

Purpose: Individuals with psychiatric disorders are at increased risk for treatment non-adherence and related complications, especially during transitions of care. Medication reconciliation is now a standard process during hospital admissions that is uniformly recommended by international organizations to aid in safe and effective care transitions. Pharmacy-led medication reconciliation (PMR) practices are poised to represent a standardized method of reconciliation attempt within this underserved population with complex medication histories. Methods: A retrospective cross-sectional study using medical chart review was conducted for all adults admitted to the inpatient psychiatric service at a community hospital in Buffalo, NY, during 2 months in 2018. Outcomes were 30- and 180-day psychiatric readmission rates, 30- and 180-day visit rates to the outpatient comprehensive psychiatric emergency program (CPEP), and composite 30- and 180-day relapse. Receipt of pharmacy-led medication reconciliation was identified from pharmacy documentation in the electronic medical record. Results: 78% of patient’s medication lists on admission were reconciled, with 49% of reconciliations made by the inpatient pharmacy. Presence of a PMR did not alter the odds of inpatient readmission alone, however patients without a PMR were found to have 2.13 times higher odds of visiting the hospital’s outpatient CPEP within 30-days (P = .012) and 1.9 times higher odds of any composite psychiatric relapse within 30-days (P = .024). Conclusions: Implementation of hospital-wide pharmacy-led medication reconciliation on admission may help reduce psychiatric relapse across multiple care settings.

Development, pilot implementation, and preliminary assessment of a transition process for youth living with HIV

PurposeTo describe the development and pilot implementation of a transition process for youth living with human immunodeficiency virus (HIV) and to assess the perceptions of the process among youth living with HIV (YLHIV), their caregivers, and clinical staff. Design and methodsA multidisciplinary core planning team developed a transition planning framework and process. With the assistance of the appropriate hospital departments, we created educational material for patients and caregivers and a flowsheet for documentation in the electronic medical record (EMR). Staff were trained on implementation of the process and documentation in the EMR. To assess the process, we surveyed staff, YLHIV, and caregivers for feedback. ResultsOur transition process was informed by our goal to provide transition support that could respond to a variety of patient factors. We developed a process focused on four stages: 1. Introduction to Transition, 2. Building Knowledge and Skills, 3. Growing in Independence, and 4. Adult Care Ready. Each stage contains competencies for the patient and tasks for the care team. The pace of proceeding through the stages is determined by completion of competencies rather than patient age. Results from youth and staff showed that the transition process and informational material were helpful. ConclusionWe developed a transition process for YLHIV and implemented this process in an HIV clinic. Initial survey data shows that youth, caregivers, and staff found this strategy helpful. Practice implicationsThis pilot process may serve as a source of guidance to other clinics seeking to establish their own transition process.

Initial Assessment Form of Medical Record Document: Is It Important to Complete?

Medical record document completeness is crucial because it serves as a means of communication, quality evaluation, payment, and legal protection. A preliminary study showed that none of the initial assessment forms in the outpatient unit of Puri Bunda Mother and Child Hospital were filled completely. This study aimed to explore the causes of incomplete initial assessment forms to avoid lawsuits against the hospital. The method used was qualitative research with a case study approach. Data were collected using triangulation, which included in-depth interviews with 15 participants, flow observations, and document studies on 150 medical record files. Data were analyzed using thematic analysis. The document study found none of the medical records with a complete initial assessment form (0%). A total of 141 documents (94%) were not filled at all, and only 9 (6%) of the initial assessment forms were filled in certain fields. The flow observation disclosed that file availability was one of the contributing problems to the completeness of filling. Seven reasons for incomplete initial medical assessment documents were categorized into individual internal and external factors. The internal factors include the lack of awareness of doctors and feeling a high workload, and the external factors include the absence of communication between management and doctors, unavailability of work procedures, the absence of a reward and punishment system, the format and availability of initial assessment forms, and individual culture.

Emergency Room Medical Record Modification to Optimize Patient Education at X Hospital

Regularly delivering information to patients and their families becomes a challenge for medical personnel in the Emergency Room (ER). Patients, or their families, often do not remember that education about their illness has been delivered. It can also happen because family members who took the patients into the emergency room differed from those who received the education. This situation can lead to misunderstandings, especially if there are legal problems in the future. This study aimed to find the priority problem in the hospital, the root of the problem, and solutions to optimize patient education in the ER. The methods used in the problem-finding were interviews, Focus Group Discussions (FGD), and USG (Urgency, Seriousness, and Growth) scoring. The solution selection method used FGD, fishbone analysis, 5-whys table, and CARL (Capability, Accessible, Readiness, and Leverage) scoring. The problem found was the lack of optimal patient education in the ER. The priority of the root of the problem found was no written documentation in the patient's medical record regarding providing education to patients or families. The chosen solution was to modify the ER medical record by including a checklist of educational points and a column for patients or families to sign. Further research is needed to prove the effectiveness of this medical record modification in optimizing education in the ER.

Synthesizing the Evidence: Best Practices for Trauma-Informed Care Education Across the Health Professions Workforce.

Purpose: Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but TIC education for clinicians has not been well examined. To remedy this, the authors conducted a multidisciplinary, scoping literature review to discern best practices for design, implementation, and evaluation of TIC curricula for health care professionals. Method: The research team searched Ovid Medline, Cochrane Library, Elsevier’s Scopus, Elsevier’s Embase, Web of Science, and the Published International Literature on Traumatic Stress database. Two independent reviewers screened 1,824 abstracts and excluded 1,697. After assessing 127 full-text articles, they excluded 76 based on predefined exclusion criteria; subsequently, they identified 4 additional articles through hand searching. Results: Fifty-five studies met inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma, responding to disclosures, defining trauma, and understanding trauma’s impact on health. Forty-seven of the studies included curricular evaluations, most commonly pre- and postsurveys. A minority used only postsurveys or a retrospective pre–post survey. The most common survey items included confidence in TIC skills, training content knowledge, participant demographics, and attitudes regarding the importance of TIC. Discussion: Future curricula should include applying a foundational lens of cultural humility, understanding the impacts of marginalization and oppression on individual and collective experiences of trauma, interprofessional collaboration, and incorporating survivors’ voices in education. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care providers. Significance: Although medical school curricula are increasingly including TIC education, best practices in TIC curricula have not been developed. This scoping review lays the groundwork for evidence-based strategies for the design, implementation, and evaluation of TIC curricula in the health professions.

Incomplete Inpatient Medical Record Documents at Hospital

The medical record contains the patient's identity, examination, treatment, actions and other services that have been provided to patients. There were incomplete integrated patient progress notes 61% and incomplete medical resumes 73%. The research intended to analyze the aspects that caused the incompleteness of inpatient medical record documents at the Besuki Hospital. This research used a qualitative method with data collection techniques interviews, observation dan documentation. The subjects in this study were 1 head of medical records and 5 medical record officers. The result showed that the factors causing the incompleteness of inpatient medical record documents from the motivational variable were that there was still no award and punishment for medical record officers. Opportunity variables were the absence of incomplete record cards, medical record officers who have never attended any training at all, SOPs for checking the completeness of medical records missing and having never been socialized. The ability variable was that there were medical record officers who did not have a minimum education of medical recorders, the knowledge of officers is still lacking and there were officers who had work experience of less than 2 years. Abstrak: Rekam medis berisi identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Berdasarkan hasil observasi diketahui bahwa terdapat ketidaklengkapan CPPT sebesar 61% dan ketidaklengkapan resume medis sebesar 73%. Penelitian bertujuan untuk mengidentifikasi dan menganalisis penyebab ketidaklengkapan rekam medis rawat inap di RSUD Besuki. Jenis penelitian adalah kualitatif, pengumpulan data dilakukan dengan wawancara mendalam, dokumentasi, dan observasi. Subyek pada penelitian ini yaitu 1 ketua rekam medis dan 5 petugas rekam medis. Hasil penelitian menunjukkan faktor penyebab ketidaklengkapan dokumen rekam medis rawat inap dari variabel motivasi yaitu masih belum ada pemberian penghargaan dan hukuman untuk petugas rekam medis. Variabel kesempatan yaitu belum adanya kartu catatan ketidaklengkapan, petugas rekam medisbelum pernah mengikuti pelatihan sama sekali, SOP kegiatan pengecekan kelengkapan rekam medis hilang dan belum pernah disosialisasikan. Variabel kemampuan yaitu terdapat petugas rekam medis yang tidak memiliki pendidikan minimal D3 Rekam Medis, pengetahuan petugas rekam medis masih kurang dan ada petugas memiliki pengalaman kerja kurang dari 2 tahun.

Medical record documentation: What to do, and what to avoid

Medical record documentation serves as a reminder of previous discussions with patients and what happened during their visits, a reimbursement justification for services, a communication tool to coordinate care with current and future clinicians, and a basis for defense in legal or regulatory matters.

Implementation of a proactive outreach program to patients with gastrointestinal malignancies starting new chemotherapy regimens.

340 Background: Gastrointestinal oncology patients (GIOP) at Fox Chase Cancer Center (FCCC) disproportionately require emergency department (ED) or urgent care (UC) evaluation due to chemotherapy-related adverse events (CRAE). Between January 2014 - June 2018, GIOP comprised 24% of visits to the FCCC ED and 29% of visits to the FCCC UC center, though specific patient and disease characteristics are unavailable. Prior to March 2022 there was no process to proactively contact patients to assess for CRAE or provide symptom management education (SME) following the administration of a new intravenous chemotherapy (IVC). This contributed to a perception of higher volumes of patient-initiated phone calls for acute CRAE management, SME, and UC/ED evaluations as compared to other disease sites, leading to patient and provider dissatisfaction. Methods: We aimed to contact at least 50% of all GIOP starting new IVC through a standardized nurse-initiated phone call within 72 hours of a patient’s first infusion by June 2022. A multidisciplinary team of medical oncology fellows, nurses, and clinic managers launched this initiative through participation in the ASCO Quality Training Program. A series of Plan-Do-Study-Act (PDSA) cycles were conducted over 12 weeks. All GIOP starting a new IVC were electronically identified on a weekly basis by the infusion room scheduling system. Clinic nurses called patients from this list to assess symptoms, provide SME, and advise early intervention for CRAE. A smart phrase was developed for efficient yet comprehensive documentation in the electronic medical record (EMR). EMR documentation was reviewed weekly to determine if calls were made within 72 hours of treatment, which guided subsequent PDSA cycles. Results: From March 14, 2022 to June 3, 2022, a list of all GIOP starting a new IVC was generated and consistently distributed weekly to nurses embedded in 6 GI oncology clinics. Over 12 weeks, 40 (56%) of 71 patients receiving a new IVC were called and 37 (52%) of the patients were called within 72 hours. Of the patients who were called, 93% were called within the intended time frame. Nurses documented their outreach calls in the EMR utilizing a standardized smart phrase to summarize CRAE assessments and SME. Acute or unresolved issues were triaged to the patient’s primary oncology team for further guidance. Conclusions: This initiative successfully introduced a nursing-led outreach phone call to GIOP starting a new IVC, though additional PDSA cycles are needed to achieve more consistent outreach. We plan to standardize outreach to patients with organized SME while striving to automate performance monitoring. Further evaluation of this intervention, which will eventually better identify patients at highest risk for acute unplanned care needs, will assess the impact of patient-reported outcomes and health care utilization.

S2294 Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios

Introduction: Endoscopic therapy is effective for management of early esophageal cancer (EC), however serious complications such as bleeding and perforation can occur. Patient selection, optimization of co-morbidities and peri-procedure management help mitigate risk and improve patient outcomes. We present a patient with decompensated cirrhosis who required complex peri-procedure planning prior to endoscopic treatment of early EC. Case Description/Methods: A 71-year male with decompensated cirrhosis (portal hypertension, esophageal varices, ascites) and recent DVT on apixaban was found to have a 1cm raised focal lesion at the GEJ; biopsies revealed high-grade dysplasia (HGD). He was referred for endoscopic mucosal resection (EMR). After extensive discussion with hematology, patient was admitted for anticoagulation management with intravenous (IV) heparin. EGD confirmed an 8mm nodule at the GEJ (Figure 1A,B,C). Grade 3 non-bleeding esophageal varices were noted at the GEJ and in the distal esophagus, prohibiting safe EMR. Biopsies again showed HGD. After multidisciplinary tumor board discussion, a transjugular portosystemic shunt (TIPS) was performed to decompress the portal system and reduce bleeding risk from the planned EMR. Doppler ultrasound a few weeks later confirmed patent TIPS. Repeat diagnostic EGD showed decompression of varices. EUS revealed a mucosal lesion with no lymphadenopathy. Biopsy revealed intramucosal adenocarcinoma. Based on this evaluation and after detailed discussion with the patient, EMR was planned with appropriate anticoagulation management. En-bloc multiband mucosectomy was performed (Figure 1D,E). Intraprocedural bleeding was controlled with band ligation and hemostatic spray (Figure 1F). Patient remained inpatient for observation on octreotide and IV pantoprazole drip without further bleeding. Apixaban 2.5mg was resumed on day 3 and he was discharged home on acid suppression. Pathology confirmed well-differentiated adenocarcinoma, pT1a. Tumor board discussion recommended continued endotherapy (cryotherapy) to the residual dysplastic Barrett’s mucosa which he is tolerating well. Discussion: Endoscopic treatment is effective for the management of early EC. However, when complex scenarios present in an elderly frail patient, multidisciplinary collaborative management and stepwise risk-mitigation strategies need to be in place to minimize morbidity and maximize success (Table). Tumor board and shared decision making are key patient centric strategies that reflect best practice.Figure 1.: A: Nodular distal esophageal lesion; B: Lesion in high-definition white light endoscopy (HDWLE); C: Lesion in narrow band imaging (NBI), D: Band placed at the base of the lesion, E: EMR defect, F: Hemostatic spray was used to achieve hemostasis of an area of focal bleeding after EMR. Table 1. - Risk Mitigation Strategies in Complex Endoscopy Practice – Best Practice Principles Pre-procedure consultation (nonemergent diagnostic/elective procedures) Pre-procedure planning (labs, imaging) Optimization of treatment for co-morbidities Anesthesia consultation Detailed high-risk informed consent Shared decision making Multidisciplinary GI tumor board discussion Medical record documentation Guideline-based anti-thrombotic management Appropriate procedure back-up and support (IR, surgery, radiology, critical care)

The Accuracy of In-State Prescription Monitoring Program Database and Electronic Medical Records Compared to Urine Toxicology Screening in Total Joint Arthroplasty Preoperative Evaluation.

Preoperative narcotic use is associated with poor postoperative pain management and worse outcomes after total joint arthroplasty (TJA). Therefore, identifying controlled substance use preoperatively is necessary. Electronic medical records (EMRs), prescription monitoring programs (PMP), or urine toxicology screening (UTS) are most commonly used. This study aims to compare the accuracy of EMR and PMP versus UTS to determine whether UTS should be implemented as standard of care in TJA preoperative assessment. Preoperative UTS was performed for primary or revision TJA from November 1, 2018, to March 31, 2019. Patient demographics, medical history, prescription history, and UTS results were retrospectively recorded. Prescription monitoring program and EMR were queried for prescription history in the past 2 years. The accuracy of EMR and PMP compared with UTS was calculated. Multivariable logistic regression analysis was performed to identify patient predictors associated with UTS+. Thirty of 148 patients had UTS+. Positive urine toxicology screening was more common in patients younger than 58 years, White race, and undergoing revision surgery. Electronic medical record and PMP documentation had the highest sensitivity (73.3%), specificity (92.4%), positive predictive value (71.0%), and negative predictive value (93.2%). Patients with higher odds of UTS+ include current/former smokers, those with a history of alcohol abuse, drug abuse, hepatitis C diagnosis, and mental illness. For patients without any risk factors for having a UTS+, the use of EMR and PMP may be sufficient to evaluate for controlled substance use; however, UTS should be considered in patients who present with one of the risk factors for UTS+.

Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020

Quantitative Analysis is a review of certain parts of the contents of medical records to find deficiencies, especially those related to the documenting of medical records. Coronavirus Disease 2019 (Covid-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2). The purpose of this study is to find out the implementation of the Covid-19 Isolation Room Patient Medical Record Document Review at RSU Imelda Pekerja Indonesia in 2020. The population is all patients treated in the Covid-19 Isolation Room in 2020 as many as 182 people, the study sample is all patients treated in the Covid-19 Isolation Room in October as many as 48 people. The DRM review was conducted on four variables. From the results of the study obtained that the Review of Timeliness of appropriate DRM Returns as much as 35.41%; Review of the Accuracy of Filling out DRM for the exact Opname Warrant Form (SPO) 31.25%, the appropriate IGD Assessment Form 52.08%, the right Medical Resume Form 100%, and the proper Observation Form 66.67%; DRM Readability Review for Opname Warrant Form (SPO) which reads 100%, IGD Assessment Form that reads 77.08%, Medical Resume Form that reads 100%, and Observation Form that reads 72.92%; Drm Completeness Review for Screening Form found in 68.75% of documents, Triage Form found in 77.08% documents, Internal Transfer Form found on 89.58% of documents, Discharge Planning Form found on 81.25% of documents.For General Consent Forms, Inpatient Assessments, CPPT Forms, Observation Forms, and Information and Education Forms are found in all documents that are 100%. It is recommended that the existing SPO socialization prioritizes the accuracy of filling out medical records qualitatively, not limited to the completeness of the form only.

Machine Learning Prediction of Suicide Risk Does Not Identify Patients Without Traditional Risk Factors.

Objective: To determine whether predictions of suicide risk from machine learning models identify unexpected patients or patients without medical record documentation of traditional risk factors.Methods: The study sample included 27,091,382 outpatient mental health (MH) specialty or general medical visits with a MH diagnosis for patients aged 11 years or older from January 1, 2009, to September 30, 2017. We used predicted risk scores of suicide attempt and suicide death, separately, within 90 days of visits to classify visits into risk score percentile strata. For each stratum, we calculated counts and percentages of visits with traditional risk factors, including prior self-harm diagnoses and emergency department visits or hospitalizations with MH diagnoses, in the last 3, 12, and 60 months.Results: Risk-factor percentages increased with predicted risk scores. Among MH specialty visits, 66%, 88%, and 99% of visits with suicide attempt risk scores in the top 3 strata (respectively, 90th-95th, 95th-98th, and ≥ 98th percentiles) and 60%, 77%, and 93% of visits with suicide risk scores in the top 3 strata represented patients who had at least one traditional risk factor documented in the prior 12 months. Among general medical visits, 52%, 66%, and 90% of visits with suicide attempt risk scores in the top 3 strata and 45%, 66%, and 79% of visits with suicide risk scores in the top 3 strata represented patients who had a history of traditional risk factors in the last 12 months.Conclusions: Suicide risk alerts based on these machine learning models coincide with patients traditionally thought of as high-risk at their high-risk visits.

DOES PROVIDER PAYMENT METHOD IMPROVE THE COMPLETENESS OF MEDICAL RECORDS? A STUDY ON THE IMPACT OF THE CASEMIX SYSTEM ON MEDICAL RECORD DOCUMENTATION IN A PUBLIC SPECIALIST HOSPITAL IN WEST SUMATRA PROVINCE, INDONESIA

In 2010, the Government of the Republic of Indonesia implemented a casemix system called INA-CBG as a provider payment method for the National Health Insurance program for the poor One of the obstacles faced in practice was the incompleteness of medical record documentation. This cross-sectional study, using quantitative and qualitative research methods, aimed to review the impact of casemix implementation on medical record documentation. The study was conducted at the National Stroke Centre Hospital, Bukittinggi, West Sumatra Province, Indonesia, which is the only government specialist hospital for stroke patients in Indonesia. We reviewed 244 and 559 medical records from 2008 and 2012, respectively. This study used chi-square test to differentiate the completeness of medical records before and after the implementation of the casemix system. Qualitative data were collected through in-depth interviews with senior doctors, the head of the medical records department, and a focus group discussion with six senior medical record officers for detailed investigations of the incompleteness of medical records. This study found that the completeness of medical records improved from 59.4% to 73.9% with casemix implementation. The variables that increased the completeness of medical records were the admission date, discharge date, length of stay, age, secondary diagnosis, and secondary procedure. In conclusion, implementation of the casemix system improved the completeness of medical records and had a positive impact on medical record documentation.

Analysis of Differences in Timeliness of Providing Outpatient Medical Record Documents in the Terminal Digit Filling Filing System at Hospital

Analysis of Differences in Timeliness of Providing Outpatient Medical Record Documents in the Terminal Digit Filling Filing System at Hospital