Medical record audit

OBJECTIVES: The aim of this clinical audit was to assess patient demographics, outcomes and experience with care in patients who received acupuncture in a private practice setting in the United Kingdom. METHODS: Demographic and clinical data were extracted from patients' records over a 7-year period. The Measure Yourself Medical Outcomes Profile (MYMOP) questionnaire and an adapted Patient Global Impression of Change (PGIC) scale were used routinely to monitor patient outcomes over an 18-month period...

OBJECTIVE: Leverage electronic health record (EHR) audit logs to develop a machine learning (ML) model that predicts which notes a clinician wants to review when seeing oncology patients. MATERIALS AND METHODS: We trained logistic regression models using note metadata and a Term Frequency Inverse Document Frequency (TF-IDF) text representation. We evaluated performance with precision, recall, F1, AUC, and a clinical qualitative assessment. RESULTS: The metadata only model achieved an AUC 0...

Background Oral surgical records contain all the information regarding a patient, including their history, clinical findings, diagnostic test results, pre-and postoperative care, progress, and medication. Notes that are properly drafted will help the physician argue that the course of therapy is appropriate. Several tools have been created for auditing clinical records; one such tool that may be used for any inpatient specialty is the CRABEL score system developed by CRAwford-BEresford-Lafferty. Aims This research aimed to evaluate the oral surgical records using the CRABEL scoring system for quality assessment...

Data curation for a hospital-based cancer registry heavily relies on the labor-intensive manual abstraction process by cancer registrars to identify cancer-related information from free-text electronic health records. To streamline this process, a natural language processing system incorporating a hybrid of deep learning-based and rule-based approaches for identifying lung cancer registry-related concepts, along with a symbolic expert system that generates registry coding based on weighted rules, was developed...

INTRODUCTION: the risk management system is useful to identify, analyze, and reduce the risk occurrence of adverse events (AEs) in health services. This system suggests useful improvements to patients and to the whole institution and also contributes to the acquisition of a collective and organizational safety culture. This study presented a state of the art of the management of AEs identified in different services of a regional hospital in the north of Morocco. METHODS: this is a retrospective cross-sectional exploratory study carried out from 2017 to 2019 using observations and semi-structured interviews, which were recorded, re-transcribed, and analyzed...

BACKGROUND/AIM: Early phase clinical trials (EPCTs) assess the tolerability of novel anti-cancer therapeutics in patients with advanced malignancy. Patient selection is important given the modest clinical benefit and time commitments for trials. Prognostic scores have been developed to facilitate identification of high-risk patients. This study aimed to compare five prognostic scores to predict survival for patients on an EPCT. PATIENTS AND METHODS: We performed a retrospective review of patients enrolled in EPCT at Liverpool Hospital, Sydney, from 2013 to 2023...

This multicentre, retrospective medical record audit evaluated opioid analgesia prescribing within a Victorian metropolitan public hospital network. The study included all surgical patients discharged between January 2012 and December 2020 with one or more discharge prescriptions from three metropolitan hospitals ( n  = 117,989). The main outcome measures were mean oral morphine equivalent daily dose (OMEDD), mean number of opioid types and proportion of patients prescribed one or more slow-release opioids on discharge...

PURPOSE: It is unclear whether the Geriatric-8 (G8) has the accuracy to preselect patients for complete geriatric assessment, and has the ability to predict adverse outcomes in patients with colorectal cancer (CRC). We therefore aimed to determine whether the G8, or other variables present in the medical record, are applicable in predicting 30-day adverse outcomes in older patients undergoing surgery for CRC. METHODS: We performed a retrospective cohort study involving patients ≥70 years who had surgery for CRC between 2018 and 2020 in a general hospital in the Netherlands...

OBJECTIVE: To identify patients presenting to an acute medical hospital with common signs and symptoms that occur in people with eating disorders (EDs), and determine by retrospective file audit if these are diagnosed cases of an ED. METHOD: The investigators screened electronic medical records of people 16 years and older for common signs and symptoms of an ED such as hypokalemia, in patients presenting to an acute hospital in Sydney, Australia from 2018 to 2020...

OBJECTIVES: To present a new method for displaying blood utilization data based on analysis of decision time intervals (DTIs). METHODS: Retrospective study of patients treated in a medical intensive care unit (ICU), surgical ICU, or postcardiac surgery ICU at an academic hospital between January 2018 and June 2023. Each patient's episode of care was divided into a series of DTIs. Transfusions during each time interval were recorded. RESULTS: In total, 16,562 patients received 6980 units of plasma and 21,034 units of red blood cells during 111,557 time intervals of care...

BACKGROUND: Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning. OBJECTIVES: To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke. DESIGN AND METHODS: A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit...

BACKGROUND: The carbon footprint of Canada's health sector is among the worst in the world, responsible for 4·6% of Canada's total greenhouse gas emissions. A quarter of emissions from Canada's health sector are linked to pharmaceuticals, including metered dose inhalers (MDIs). MDIs use propellants, such as hydrofluorocarbons, which act as greenhouse gas emissions and contribute to the health-care sector's overall carbon footprint. The objective of this study was to describe MDI prescribing, dispensing, usage, and waste patterns at The Ottawa Hospital (Ottawa, ON, Canada)...

Considerable advances in the diagnosis and treatment of cancer have made a huge impact on morbidity and mortality from neoplastic diseases. However, cancer remains the leading cause of death across the world. This is a retrospective study carried out at a tertiary cancer care centre (Kidwai Memorial Institute of Oncology, Bangalore) in South India. Case records of all cancer patients who died while receiving inpatient treatment between January 2022 and December 2022 under the Department of Medical Oncology were reviewed and studied...

BACKGROUND: The perinatal period is a time of 'high risk' for new and recurrent episodes of mental illness with 0.1-0.2% of birthing parents requiring admission to specialist mental health units in the months after birth. The prevalence and role of trauma in the lives of birthing parents (most commonly mothers) experiencing severe perinatal mental illness is not well known. METHOD: In a new perinatal mental health unit in Sydney Australia, a retrospective audit of trauma prevalence was undertaken using patient completed questionnaires and electronic medical record data...

BACKGROUND AND AIM: Effective clinical event classification is essential for clinical research and quality improvement. The validation of artificial intelligence (AI) models like Generative Pre-trained Transformer 4 (GPT-4) for this task and comparison with conventional methods remains unexplored. METHODS: We evaluated the performance of the GPT-4 model for classifying gastrointestinal (GI) bleeding episodes from 200 medical discharge summaries and compared the results with human review and an International Classification of Diseases (ICD) code-based system...

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs. METHODS: Retrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019...

OBJECTIVES: To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff. METHODS: This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records...

BACKGROUND: The focus on pain assessment using a single, one-dimension pain assessment scale can be problematic. Locally, challenges we faced with this were; a) pain was percieved as not being effectively managed, b) patients with chronic pain were not having their pain adequately controlled, and c) misconceptions and subsequent confusion between health care teams and patients related to what pain intensity scores mean to each individual. AIMS: The purpose of this paper is to describe an evidence-based practice project aiming at improving pain assessment through the implementation of a Functional Pain Scale (FPS) on an adult inpatient cardiothoracic unit...

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30...

AIM: Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis. METHODS: Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023...