Search

The primary purpose of medical records is to support patient care. It is a means of communication and secondarily, it is an important medicolegal document. Current standards of clinical records are variable. The aim of this study was to assess the adequacy of case notes in a tertiary care hospital and compare it with that of world standards. 231 case records of inpatients in the general surgery department who were discharged were audited retrospectively. Out of 53 standards analyzed, 7 had 100% compliance. More than 75% of compliance was achieved in 30/53 standards. A significant lapse in record keeping was found in daily entries by doctors, the timing of entries, details of initial assessment, and daily progress notes. Maintaining high-quality clinical record is an important part of our responsibility. Deficiencies show up in formal audits of case records. Regular orientation programs to improve the quality of clinical records and regular auditing of case notes are required to ensure adequacy. [ABSTRACT FROM AUTHOR]

Introduction: The minimum data set is a standard method for collecting key data elements, which will finally improve healthcare and quality of treatment services. Electronic documentation in the intensive care unit (ICU) has a significant effect on the quality of data. In addition, using structured data and standard formats can facilitate documentation of progress note data. Therefore, the aim of this study was to create a minimum data set for an effective design and implementation of electronic documentation of progress note in the ICU. Material and Methods: This is an applied qualitative study conducted in the general intensive care unit of Namazi hospital in Shiraz, which is the largest education and treatment center in Shiraz and the only referral hospital in Southern Iran. In this study, four stages were used for designing the minimum data sets of electronic progress note: 1. Using English literature, 2. Local expert review, 3. Designing prototypes, and 4. Conducting group sessions. Finally, data were analyzed using descriptive statistics through SPSS 21 software. Results: The minimum data set for electronic documentation of progress note in the ICU included the two demographic and clinical sections. In addition, the clinical data were classified into 11 major groups, each consisting of other items. Meanwhile, 46.8% (66 out of 141) of information items were obtained from reviewing the literature and 53.2% (76 out of 141) from interviews. In group sessions, 99.29% of information items were finalized by experts. Conclusion: It is essential to create a standard and structured minimum data set for the electronic design and implementation of progress note data. In such a case, accurate, thorough and timely electronic documentation in presenting instantaneous reports on the status of patients is effective in management and clinical decision-makings. [ABSTRACT FROM AUTHOR]

Medical students have routinely documented patient encounters in both inpatient and outpatient care venues. This hands-on experience has provided a way for students to reflect on patient encounters, learn proper documentation skills, and attain a sense of being actively involved in and responsible for the care of patients. Over the last several years, the practice of student note writing has come into question. Institutional disincentives to student documentation include insurance regulations that restrict student documentation from substantiating billing claims, concerns about the legal status of student notes, and implementation of electronic medical records that do not allow or restrict student access. The increased scrutiny of the medical record from pay-for-performance programs and other quality measures will likely add to the pressure to exclude students from writing notes. This trend in limiting medical student documentation may have wide-ranging consequences for student education, from delaying the learning of proper documentation skills to limiting training opportunities. This article reviews the educational value of student note writing, the factors that have made student documentation problematic, and the potential educational impact of limiting student documentation. In addition, it offers some suggestions for future research to guide policy in this area. [ABSTRACT FROM AUTHOR]

Background The University of Minnesota Medical Center (UMMC) is a tertiary care facility, which has had a comprehensive antimicrobial stewardship program (ASP) for 12 years. Methods The antimicrobial stewardship team is comprised of a full-time PharmD and ID staff physicians. Recommendations are placed in the electronic medical record as a progress note. Verbal recommendations may also be made. Results There was a downward trend in Hospital-acquired (HA) C. difficile diarrhea from 2007 to 2014 from 1.2 to 0.5/1000 patient-days (pt day). Rates appear stable from 2014 to 2019 with adjustment for change to NHSN lab-based CDI surveillance (Figure 1). From 2009 to 2019 a decrease was seen in VRE hospital-acquired infections (HAI) from 0.53 to 0.21/1,000 patient-days and in MRSA HAIs from 0.2 to 0.14/1,000 patient-days. Newly acquired ESBL HAIs have remained relatively stable from 2009 to 2019 at 0.09 to 0.05/1,000 patient-days. CRE HAIs are low but stable rates at 0.02/1,000 patient-days (Figure 2). We track antimicrobial utilization for internal and national reporting (starting in July 2017). A SAAR for all Antibacterial agents (ICUs, wards, and oncology units) of 1.33 in 2018. Our top four agents average DOT; piperacillin/tazobactam (66.81), cefepime (34.40), oral levofloxacin (23.56) and intravenous meropenem (21.49). We demonstrate lower average DOT for our restricted antimicrobials (206.21) as compared with our nonrestricted antimicrobials (236.74) (Figure 3). Cost savings continued from year to year. After adjusting for inflation annually, our expected costs ($84.08) compared with actual costs ($40.12 ytd 2019), demonstrates effective cost management of antimicrobial agents. (Figure 4) Conclusion We observed a decrease in HAIs VRE and C. difficile infections after 3 years of operation, and MRSA after 5 years. This downward trend has continued. ESBL HAIs remain relatively stable and CRE are stable at low rates but remain emerging HAIs of concern. We are now focusing efforts on limiting unneeded fluoroquinolone and carbapenem use. We continue to analyze our SAAR data and internal DOT data to identify areas of opportunity to improve antimicrobial use. The ASP outcomes have continued to cost justify ongoing efforts. The effects of the program and the Infection Prevention Department appear to be synergistic. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Patients discharged on intravenous antibiotics require regular monitoring by an infectious disease (ID) specialist or other provider familiar with outpatient parenteral antibiotic therapy (OPAT). However, the lab monitoring and outpatient follow-up plan outlined prior to discharge is not always realized. We are working to understand what steps the discharging hospital can take to improve the outpatient monitoring and follow-up for patients on OPAT, who are discharged to a wide variety of institutions. We studied whether documenting the OPAT plan in a standardized note led to increased inclusion of that plan in the discharge documentation and thus to improved lab monitoring and outpatient follow-up for our patients. Methods We compared the pre- and post-intervention frequency of seven key OPAT elements (antibiotic, duration, end date, indication, follow-up appointment, recommend labs, fax number for labs) in the discharge documentation. Pre-intervention, this information was documented by the inpatient ID service in the Problem List (overview) section of the electronic health record. Post-intervention, OPAT plans were documented within standardized OPAT Progress Notes. Efficiency and clinical outcomes were: proportion of OPAT treatment weeks with laboratory monitoring; number of weeks the outpatient ID team had to track down missing laboratory results; number of "No Show" ID clinic visits; number of OPAT-related telephone encounters. Results There were 73 patients in the pre- and 68 in the post-intervention cohort. Having a formal OPAT Progress Note was associated with a significant increase in the number of OPAT elements included in the discharge documentation (7 vs. 5, P = 0.002). In addition, the entire OPAT note was included in the discharge documentation more frequently in the post-intervention cohort (3/73 vs.. 14/68, P = 0.007). However, except for reduced telephone encounters related to OPAT (2 vs. 1 per patient, P = 0.0001), there were no significant improvements in post-discharge clinical or efficiency outcomes. Conclusion Creating an OPAT Progress Note improves the capture of OPAT elements into discharge documentation. Except for reducing telephone encounters, no other benefits occurred. Future interventions will focus on improving the other measured outcomes. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]