How to Trip Rapid Review

Step 1: Select articles relevant to your search (remember the system is only optimised for single intervention studies)

Step 2: press

Step 3: review the result, and maybe amend the or if you know better! If we're unsure of the overall sentiment of the trial we will display the conclusion under the article title. We then require you to tell us what the correct sentiment is.

78,095 results for

Medical Documentation

by
...
Latest & greatest
Alerts

Export results

Use check boxes to select individual results below

SmartSearch available

Trip's SmartSearch engine has discovered connected searches & results. Click to show

1. Reimbursement for injury-induced medical expenses in Chinese social medical insurance schemes: A systematic analysis of legislative documents. (PubMed)

Reimbursement for injury-induced medical expenses in Chinese social medical insurance schemes: A systematic analysis of legislative documents. Social medical insurance schemes are crucial for realizing universal health coverage and health equity. The aim of this study was to investigate whether and how reimbursement for injury-induced medical expenses is addressed in Chinese legislative documents relevant to social medical insurance. We retrieved legislative documents from the China National (...) Knowledge Infrastructure and the Lawyee databases. Four types of social medical insurance schemes were included: urban employee basic medical insurance, urban resident basic medical insurance, new rural cooperative medical system, and urban and rural resident medical insurance. Text analyses were conducted on all identified legislative documents. As a result, one national law and 1,037 local legislative documents were identified. 1,012 of the 1,038 documents provided for reimbursement. Of the 1,012

Full Text available with Trip Pro

2018 PLoS ONE

2. Understanding Paper-Based Documentation Practices in Medical Resuscitations to Inform the Design of Electronic Documentation Tools. (PubMed)

Understanding Paper-Based Documentation Practices in Medical Resuscitations to Inform the Design of Electronic Documentation Tools. Despite growing use of electronic health records, many resuscitation settings still use paper-based documentation. The fast-paced and safety-critical nature of trauma and medical resuscitation environments pose challenges for real-time documentation. This study aims to understand paper-based documentation practices and inform the design of efficient electronic (...) documentation solutions for supporting safety-critical medical processes.Data were collected through in situ observations of nurse documenters during resuscitation events and postevent interviews with nurses. These data were analyzed using frequency distribution and qualitative, open-coding techniques. Data analysis focused on the following 3 main documentation factors: temporal distribution of documentation, total number of filled out sections on the paper flow sheet across all resuscitations

2018 Pediatric Emergency Care

3. Assessing the Readability of Medical Documents: A Ranking Approach (PubMed)

Assessing the Readability of Medical Documents: A Ranking Approach The use of electronic health record (EHR) systems with patient engagement capabilities, including viewing, downloading, and transmitting health information, has recently grown tremendously. However, using these resources to engage patients in managing their own health remains challenging due to the complex and technical nature of the EHR narratives.Our objective was to develop a machine learning-based system to assess (...) used readability formula. Our ranking-based method can predict relative difficulties of medical documents. It is not constrained to a predefined set of readability levels, a common design in many machine learning-based systems. Furthermore, the feature set does not rely on complex processing of the documents. One potential application of our readability ranking is personalization, allowing patients to better accommodate their own background knowledge.©Jiaping Zheng, Hong Yu. Originally published

Full Text available with Trip Pro

2018 JMIR medical informatics

4. Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study (PubMed)

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study We hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital-attending physicians' decision-making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D-dimer result were reported by ED physicians (...) in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital-attending physicians.In an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D-dimer measurement (≥1.0 μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected

Full Text available with Trip Pro

2017 Acute medicine & surgery

5. The Potential Impact of Scribes on Medical School Applicants and Medical Students with the New Clinical Documentation Guidelines. (PubMed)

The Potential Impact of Scribes on Medical School Applicants and Medical Students with the New Clinical Documentation Guidelines. The presence of scribes in various specialties, including internal medicine, is being heralded as a way to decrease clinician documentation time and burnout. Many medical school applicants become scribes to understand life as a doctor and gain clinical experience. Scribing is already perceived by some as a new key to successfully gaining entrance to medical school (...) . One season of our admissions data showed that scribes were more likely to be admitted (OR = 1.61). Scribes may also inadvertently make it harder for medical schools to secure clinical placements for medical students. While trained scribes are highly valued by providers struggling to deal with increasing documentation burdens, supervising or training scribes also requires time that cannot be devoted to teaching. Medical documentation duties could provide valuable learning experiences for medical

2018 Journal of General Internal Medicine

6. Is this a medical miracle or a medical error in documentation?

Is this a medical miracle or a medical error in documentation? Is this a medical miracle or a medical error in documentation? Is this a medical miracle or a medical error in documentation? | | May 8, 2018 25 Shares I was a foreign medical graduate who in addition to some clinical practice, had begun a career first in managed care as a utilization management coordinator and then as a clinical researcher after finishing medical school and then pursuing a public health degree. A few years ago (...) in hypoxic, wheezing, possible pneumonia, he is desaturating and requires oxygen, or in some cases, even BiPAP or — worse yet — ventilation. You mention in your notes that he has “respiratory distress.” This is where a clinical documentation improvement specialist like myself (You need to be either an RN or have a medical degree for this role in any respectable CDI program), will review the charts and ask a physician if this really is just distress or is it possible the patient can be going into a more

2018 KevinMD blog

7. Variables associated with completeness of medical record documentation in the emergency department. (PubMed)

Variables associated with completeness of medical record documentation in the emergency department. The completeness of ED medical record documentation is often suboptimal. We aimed to determine the variables associated with documentation completeness in a large, tertiary referral ED.We audited 1200 randomly selected medical records of patients who presented with either abdominal pain, cardiac chest pain, shortness of breath or headache between May-July 2013 and May-July 2016. Data were (...) collected on patient and treating doctor variables. Documentation completeness was assessed using a 0-10 point scoring tool designed for the study. A maximum score was achieved if each of 10 pre-determined important items, specific to the presenting complaint, were documented (five medical history items, five physical examination items). Data were analysed using multivariate regression.The presenting year, day and time, patient age and gender, preferred language, interpreter requirement, discharge

2019 Emergency medicine Australasia

8. Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care. (PubMed)

Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care. To quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.Retrospective cohort study.A 544-bed academic tertiary care hospital in Portland, Oregon.A total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.Data were collected from an electronic repository of medical record data and a manual (...) review of patients' discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients' discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication-related decisions.Patients were prescribed a mean of 7.1

2019 Journal of the American Geriatrics Society

9. In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study. (PubMed)

In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study. An increasing number of transitions due to substitution of care of more complex patients urges insight in and improvement of transitional medication safety. While lack of documentation of prescription changes and/or lack of information exchange between settings likely cause adverse drug events, frequency of occurrence of these causes is not clear (...) . Therefore, we aimed at determining the frequency of in-hospital patients’ prescription changes that are not or incorrectly documented in their primary care provider’s (PCP) medical record.A medical record review study was performed in a database linking patients’ medical records of hospital and PCP. A random sample (n = 600) was drawn from all 1399 patients who were registered at a participating primary care practice as well as the gastroenterology or cardiology department in 2013 of the University

Full Text available with Trip Pro

2017 BMC health services research

10. The role of state medical direction in the comprehensive emergency medical services system: a resource document. (PubMed)

The role of state medical direction in the comprehensive emergency medical services system: a resource document. Medical oversight is a fundamental component of every emergency medical services (EMS) system. The quality of physician medical direction has a significant impact upon the system and patient outcome. The lead agency for the state EMS system is a principal facet of our emergency care system, and the state EMS medical director is a vital component within this comprehensive network (...) . The selection of an experienced, qualified physician for the provision of state EMS medical direction is a critical decision. This resource document provides a snapshot of the status of state EMS medical direction in our nation in 2007 and a projection of the achievable benchmarks for the role of the state EMS medical director in the future. As an informational resource, this tool will assist state EMS officials, legislators, laypersons, and partners within the emergency care system to comprehend, create

Full Text available with Trip Pro

2017 Prehospital emergency care

11. [KAGAKU]Science Board: English translation of an outcome document

[KAGAKU]Science Board: English translation of an outcome document Outcome documents of the Science Board | Pharmaceuticals and Medical Devices Agency Please make JavaScript on and see this site. Navigation of each product type Our recommended contents Navigation of each product type Our recommended contents Outcome documents of the Science Board Here begins the text. Outcome documents of the Science Board The Third Term (-March, 2018) Subcommittees ( Cancer Sci ., 109(5):1731-1737, May 2018 (...) ) (Adv Biomed Eng., 7: 118-123, 2018) The Second Term (-March, 2016) Subcommittees ( Cancer Sci ., 107(2):189-202, February 2016) The First Term (-March, 2014) Subcommittees Pmda - Pharmaceuticals and Medical Devices Agency JCN 3010005007409 Shin-Kasumigaseki Building, 3-3-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-0013 Japan Copyright (C) Pharmaceuticals and Medical Devices Agency, All Rights Reserved. 000035280 0 Outcome documents of the Science Board /english/rs-sb-std/sb/outcome-docs/0001.html en

2018 Pharmaceuticals and Medical Devices Agency, Japan

12. Documentation of Functional Medication Management in Older Adults: A Retrospective Chart Review in Acute Care Hospitalization (PubMed)

Documentation of Functional Medication Management in Older Adults: A Retrospective Chart Review in Acute Care Hospitalization Functional skills can affect the ability of older adults to appropriately manage their medication regimens. Research evaluating a patient's functional ability or the assessment of medication management is limited.Our objective was to describe the documented components of functional medication management (FMM) in adults aged ≥65 years during an acute hospital stay (...) . The secondary objective was to describe the characteristics of the healthcare providers (HCP) who document FMM.This study was a retrospective chart review of a sample of patients aged ≥65 years admitted to medical units in a tertiary hospital from January 2013 to October 2014. FMM was defined as the steps required to take medications-including ordering, picking up, organizing, preparing, administering, and monitoring medications-and the functional abilities necessary to perform these tasks.The mean

Full Text available with Trip Pro

2016 Drugs - real world outcomes

13. Coding Discrepancies Between Medical Student and Physician Documentation. (PubMed)

Coding Discrepancies Between Medical Student and Physician Documentation. Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation.Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level (...) of service (LOS) and diagnostic code by trained, expert coders. Differences in LOS and diagnostic code were then compared between medical student and faculty documentation.A single academic health system.Third-year medical students.80 full patient evaluations and 20 postoperative visits were analyzed. Median faculty and student LOS was 4 (range 3-4) and 3 (range 0-4) respectively (p < 0.001). Students failed to document a sufficient number of elements in the evaluation, failed to specify studies ordered

2018 Journal of Surgical Education

14. Interface design dividing physical findings into medical and trauma findings facilitates clinical document entry in the emergency department: A prospective observational study. (PubMed)

Interface design dividing physical findings into medical and trauma findings facilitates clinical document entry in the emergency department: A prospective observational study. The interface design and its effect on workflow are key determinants of the usability of electronic medical records (EMRs) in the emergency department (ED). However, whether the overall clinical care can be improved by dividing the interface design of physical findings into medical and trauma findings is unknown. We (...) the time to final documentation entry and the length of ED stay between the previous (used in the first 6 months) and current systems (used in the latter 6 months). Furthermore, we stratified the patients by triage levels.The study involved 2141 patients (934 and 1207 assessed using the previous and modified EMR systems, respectively). The modified EMR in trauma patients significantly decreased the time to final documentation entry from 131.5 [interquartile range, 86.8-207.3] to 115 [78.8-161] min (p 

Full Text available with Trip Pro

2018 International journal of medical informatics

15. Electronic Medical Record in the ED: A Cross-sectional Survey of Resuscitation Documentation Practices and Perceptions Among Emergency Department Clinicians. (PubMed)

Electronic Medical Record in the ED: A Cross-sectional Survey of Resuscitation Documentation Practices and Perceptions Among Emergency Department Clinicians. The aims of this study were to describe current practices in nursing documentation of trauma and medical resuscitations across emergency departments (EDs) and explore physicians' and nurses' perceptions of electronic medical record (EMR) use for nursing documentation of resuscitations.An anonymous Web-based survey was developed (...) and distributed to a convenience sample of ED physicians and nurses in the United States.Of 438 respondents, 154 were nurses; 97.2% of respondents reported that their EDs use EMR generally. Of those, 51.2% use EMR to document resuscitations. When describing documentation processes, 19% (95% confidence interval [CI], 15%-23%) reported direct documentation on EMR, 18% (95% CI, 14%-21%) reported documenting on paper before transferring to EMR, and 22% (95% CI, 18%-26%) reported simultaneously documenting on EMR

2018 Pediatric Emergency Care

16. Framing Electronic Medical Records as Polylingual Documents in Query Expansion (PubMed)

Framing Electronic Medical Records as Polylingual Documents in Query Expansion We present a study of electronic medical record (EMR) retrieval that emulates situations in which a doctor treats a new patient. Given a query consisting of a new patient's symptoms, the retrieval system returns the set of most relevant records of previously treated patients. However, due to semantic, functional, and treatment synonyms in medical terminology, queries are often incomplete and thus require enhancement (...) . In this paper, we present a topic model that frames symptoms and treatments as separate languages. Our experimental results show that this method improves retrieval performance over several baselines with statistical significance. These baselines include methods used in prior studies as well as state-of-the-art embedding techniques. Finally, we show that our proposed topic model discovers all three types of synonyms to improve medical record retrieval.

Full Text available with Trip Pro

2018 AMIA Annual Symposium Proceedings

17. Impact of an educational intervention on medical records documentation (PubMed)

Impact of an educational intervention on medical records documentation Inaccurate and incomplete documentation can lead to poor treatment and medico-legal consequences. Studies indicate that teaching programs in this field can improve the documentation of medical records. The study aimed to evaluate the effect of an educational workshop on medical record documentation by emergency medicine residents in the emergency department.An interventional study was performed on 30 residents in their first (...) year of training emergency medicine (PGY1), in three tertiary referral hospitals of Tehran University of Medical Sciences. The essential information that should be documented in a medical record was taught in a 3-day-workshop. The medical records completed by these residents before the training workshop were randomly selected and scored (300 records), as was a random selection of the records they completed one (300 records) and six months (300 records) after the workshop.Documentation

Full Text available with Trip Pro

2018 World journal of emergency medicine

18. Finding a silver lining: the importance of documenting medical tragedies (PubMed)

Finding a silver lining: the importance of documenting medical tragedies The radiation overexposure tragedy at a Columbus, Ohio, hospital impacted hundreds of patient lives and made a lasting impression on the regulation and oversight of the use of radiation medicine on a national level. Archival documentation of the incident and the current-day importance of the data collected during and after the event is discussed and highlights many of the reasons why the history of past medical disasters

Full Text available with Trip Pro

2018 Journal of the Medical Library Association : JMLA

19. Erratum: Standardized Note Templates Improve Electronic Medical Record Documentation of Neurovascular Examinations for Pediatric Supracondylar Humeral Fractures (PubMed)

Erratum: Standardized Note Templates Improve Electronic Medical Record Documentation of Neurovascular Examinations for Pediatric Supracondylar Humeral Fractures 30280128 2018 10 03 2472-7245 3 2 2018 Jun 28 JB & JS open access JB JS Open Access Erratum: Standardized Note Templates Improve Electronic Medical Record Documentation of Neurovascular Examinations for Pediatric Supracondylar Humeral Fractures. E0027ER 10.2106/JBJS.OA.ER.17.00027 eng Journal Article 2018 06 07 United States JB JS Open

Full Text available with Trip Pro

2018 JBJS Open Access

20. Data dreams: planning for the future of historical medical documents (PubMed)

Data dreams: planning for the future of historical medical documents Historical medical collections with privacy-sensitive information are a potentially rich source of social, behavioral, and economic data for a wide array of researchers. They remain relatively undiscoverable and at risk for destruction, however, because of their restricted content and challenging media formats. Team members from two institutions-the University of California, San Francisco, and the University of Texas at Austin (...) -present their respective initiatives to create digital archives and databases that address the privacy and technological challenges of such collections. In doing so, they also argue for the importance (and feasibility) of medical libraries and archives to take the initiative to preserve and make accessible historical patient data.

Full Text available with Trip Pro

2018 Journal of the Medical Library Association : JMLA

To help you find the content you need quickly, you can filter your results via the categories on the right-hand side >>>>