Impact of Laboratory Value Flowsheet in Electronic Health Record (EHR) Documentation Time

Research on the use of EHR is contradictory since it presents contradicting results regarding the time spent documenting. There is research that supports the use of electronic records as a tool to speed documentation;and research that found that it is time consuming. The purpose of this quantitative retrospective before-after project was to measure the impact of using the laboratory value flowsheet within the EHR on documentation time. The research question was: “Does the use of a laboratory value flowsheet in the EHR impact documentation time by primary care providers (PCPs)?” The theoretical framework utilized in this project was the Donabedian Model. The population in this research was the two PCPs in a small primary care clinic in the northwest of Puerto Rico. The sample was composed of all the encounters during the months of October 2019 and December 2019. The data was obtained through data mining and analyzed using SPSS 27. The evaluative outcome of this project is that there is a decrease in documentation time after implementation of the use of the laboratory value flowsheet in the EHR. However, patients per day increase therefore having an impact on the number of patients seen per day/week/month. The implications for clinical practice include the use of templates to improve workflow and documentation as well as decreasing documentation time while also increasing the number of patients seen per day. .

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection

BACKGROUND: Acute aortic dissection(AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act(EMTALA) is crucial. The study assessed emergency providers(EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients.METHODS: This retrospective study examined adult patients transferred directly from a referring emergency department(ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care(ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance(ADoEMTALA). RESULTS: There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five(36.6%) patients had ADoCC while 166(57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA(IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association(AHA) ED Departure SBP guideline(OR 1.8, 95% CI 1.03–3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care(IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA.CONCLUSION: Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.

Evaluation of a Mobile Station Electronic Health Record on Documentation Compliance and Nurses’ Attitudes

Electronic Health Record (EHR) Systems have been adopted by healthcare organizations for documentation of patient care. Often these information systems are embedded in mobile nurse stations. As part of assessing the impact of this technology it is important to determine the effect it has on charting compliance and user acceptance. Data were collected at a medical center in Taiwan in two stages. The first stage involved use of a 28-item medical review tool to measure charting compliance in 99 charts before and after implementation of the EHR system. In stage two, a survey was conducted with 709 nurse users to determine their level of mobile EHR acceptance 3 months after this documentation technology was initiated. Results demonstrated that EHR significantly improved documentation compliance in standardized data entry format (name, date, time), abbreviation, content correction/revision, patient care needs, and care goals. Analysis of data from the five categories of a user acceptance survey revealed the following results (based on a 4-point Likert scale): patient care (2.92), nursing efficiency (2.78), education and training (2.98), usability (2.61), and usage benefits (2.87). The study concluded that use of mobile nurse stations with EHR can improve documentation compliance and that although frequent system downtime needs improvement, nurses generally have positive attitudes toward this technology application.

Assessing an Educational Program to Improve Documentation and Reduce Pain in Hospitalized Patients

Few experimental studies have evaluated the efficacy of continuing educational programs aimed at the improvement of nurses’ pain-management skills. This study assessed whether a standardized educational program aimed at nurses could increase the use of the Numeric Rating Scale-11 in both documenting and reducing postoperative pain-intensity levels in hospitalized surgical patients. The study had a quasi-experimental pre- and post-intervention design. Data were collected from records of surgical patients prior to and after the standardized educational program was completed. There were no significant differences between pre- and post-intervention groups in terms of either pain-documentation frequency or pain-intensity level. The study showed no increase in the frequency of postoperative pain documentation and no reduction of surgical patients’ postoperative pain-intensity level. This finding indicates that the standardized educational program on postoperative pain management was insufficient to bring about changes in clinical practice.

Impact of an educational intervention on medical records documentation

BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medicolegal 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.METHODS: 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.RESULTS: Documentation of the majority of the essential items of information was improved significantly after the workshop. In particular documentation of the patients' date and time of admission, past medical and social history. Documentation of patient identity, requests for consultations by other specialties, first and final diagnoses were 100% complete and accurate up to 6 months of the workshop.CONCLUSION: This study confirms that an educational workshop improves medical record documentation by physicians in training.

The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital

In Uganda, nursing documentation still remains a challenge, in most of the government hospitals and some private hospitals, it remains at a manual (non-technology driven) level and omissions have been observed. Nurses continue to capture standard elements in their documentation. A mixed methods intervention study was conducted to determine knowledge and attitudes of nurses towards documentation, including an evaluation of nurses’ response to a designed nursing documentation form. Forty participants were selected through convenience sampling from six wards of a Ugandan health institution. The study intervention involved teaching nurses the importance of documentation and using of the trial documentation tool. Pre- and post-testing and open-ended questionnaires were used in data collection. The results from the close-ended questions were presented in the previous publication;the responses from the open-ended questions would then be presented. The open-ended questions regarding comments about the nursing documentation process and suggestions about the process of implementing the nursing documentation system in the ward units were considered. All participants were provided the opportunity to provide personal comments, reflections, or stories of their experiences with documentation in patient care. A thematic analysis approach was used during data analysis. The results showed that the participants had positive attitude towards documentation of patient care, but they had constraints limiting them to document, they reflected issues concerning the perceived pressure from the administrations and support to document. The study findings have implication that there is need for organizational support and to have multisite studies and extension of the documentation tool.

Medical Records Documentation of HIV/AIDS Clinical Services at Primary Health Care (PHC) Facilities and Its Implications on Continuum of Care and Operational Research in South Africa

Background: Patients medical records are used to document care processes for communication amongst healthcare workers for continued patient management. Incomplete or inaccurate documentation can adversely affect the quality of patients’ care, leading to medication and treatment errors, increased morbidity, and mortality. Quality documentation in medical records is therefore an essential component of optimal healthcare and facilitates an individual’s continuity of care. This study aimed to assess the quality of documentation of clinical data through the review of the accuracy and completeness of clinical records among newly diagnosed HIV-positive persons. The study is a sub analysis of a prospective longitudinal study that followed a cohort of 12,413 persons who were newly diagnosed with HIV infection. Severe limitations in retrieving reliable information and data became an obstacle to our research and led the study team to conduct medical records documentation and data audit to verify the accuracy and completeness of the data for newly diagnosed HIV positive persons. Methods: A cross-sectional study was conducted using routine data generated from 75 randomly selected newly diagnosed HIV positive persons aged 12-years-old and above between June 1, 2014 and March 31, 2015 in 36 purposively selected primary health care (PHC) clinics in South Africa. The facilities were selected from three high HIV-burden districts of South Africa (Gert Sibande, uThukela and City of Johannesburg). Results: Significant differences in the accuracy and completeness of clinical records were observed between data generated through the self-assessment by the facility managers and data primarily collected through review of the patients’ clinical stationery and facility registers. 80% of the newly diagnosed HIV positive persons were not documented as screened for tuberculosis (TB) on the clinical chart and 69% of newly diagnosed clients were not clinically staged (WHO staging). Furthermore, 80% of newly diagnosed HIV positive persons’ follow up visit dates were not documented in the patient’s clinical chart. Completeness of the data elements on the case record forms ranged from as low as 26% to a maximum of 66%. It was noteworthy that all the clients’ information documented in HIV counselling and testing registers, continuum of care registers and clinical charts were only partially completed. Conclusion: Each of the health care facilities under study had some significant gaps in medical records documentation of clinical data on newly diagnosed HIV positive persons. Data and information accuracy and completeness were a serious challenge in most facilities during the period under investigation. Of interest was the inconsistency of data recorded in the HCT registers, continuum of care and clinical charts of individual patients. This is a major impediment to HIV/AIDS comprehensive care.

Towards Lightweight Requirements Documentation

Most requirements management processes and associated tools are designed for document-driven software development and are unlikely to be adopted for the needs of an agile software development team. We discuss how and what can make the traditional requirements documentation a lightweight process, and suitable for user requirements elicitation and analysis. We propose a reference model for requirements analysis and documentation and suggest what kind of requirements management tools are needed to support an agile software process. The approach and the reference model are demonstrated in Vixtory, a tool for requirements lightweight documentation in agile web application development.

Health Workers’ Documentation Process as a Prerequisite to the Integration of Patient Care at a Regional Referral Hospital in Uganda

Background: Integrated patient care is necessary for better care outcomes. Documentation enhances the integration of care;however, in the Ugandan setting, documentation of care is poor (e.g., omissions and incomplete records) and integration of patient care is not visible. This study presents a review of patient health records that was undertaken to understand documentation of care at a regional referral hospital in Eastern Uganda. This information will help in developing a documentation model to facilitate the integration of patient care in Uganda. Methodology: This retrospective review involved 513 patient health records from the medical-surgical, pediatric, and obstetric/gynecological departments of Jinja Regional Referral Hospital. Data were collected using checklists. Stratified sampling was used to capture variations in ward unit records and identify a fair representation of each department. Data were analyzed with descriptive and inferential statistics. All analyses were performed with SPSS version 22. Results: On average, the study hospital attended to 1000 patients per day and discharged 100 patients per ward unit per month. Our record review showed that documentation by both nurses and doctors was incomplete, and care was fragmented. However, doctors documented care more often than nurses, although the integration of patient care was not evident in doctors’ documentation. Conclusion: To establish integrated patient care, documentation must meet standards set by relevant professional bodies. The findings of this study will inform the development of a feasible documentation model to facilitate the integration of patient care in Uganda.

Attempting to document and rehabilitate Aleppo between 1994 and 2011: the ramifications of pre-conflict built heritage mismanagement and the effects of the scarcity of documentation on options available for post-conflict conservation

This paper examines several aspects of the attempt at rehabilitating Aleppo and the data available about the city prior to the start of the Syrian conflict in 2011.It discusses documentation,rehabilitation and conservation practices in Aleppo,focusing on the operations between 1994 and 2011 that were coordinated by several institutions managed primarily by the Directorate of the Old City of Aleppo(DOCA)and the Gesellschaft fur Technische Zusammenarbeit(GTZ).The analysis considers not only the old city,which is inscribed on the World Heritage List,but also other historic and culturally significant areas in Aleppo.This research primarily uses notes from other scholarly resources,statements by various relevant experts,and the reports and documents produced by the DOCA,the GTZ,and UNESCO to argue that some of the practices during that period were in part responsible for overlooking important aspects and places of the city's built heritage.The paper then explains the ramification of these approaches,which are still perceptible today,on the prospects for any future efforts to safeguard the city's built heritage.

Provenance Documentation to Enable Explainable and Trustworthy AI:A Literature Review

Recently artificial intelligence(AI)and machine learning(ML)models have demonstrated remarkable progress with applications developed in various domains.It is also increasingly discussed that AI and ML models and applications should be transparent,explainable,and trustworthy.Accordingly,the field of Explainable AI(XAI)is expanding rapidly.XAI holds substantial promise for improving trust and transparency in AI-based systems by explaining how complex models such as the deep neural network(DNN)produces their outcomes.Moreover,many researchers and practitioners consider that using provenance to explain these complex models will help improve transparency in AI-based systems.In this paper,we conduct a systematic literature review of provenance,XAI,and trustworthy AI(TAI)to explain the fundamental concepts and illustrate the potential of using provenance as a medium to help accomplish explainability in AI-based systems.Moreover,we also discuss the patterns of recent developments in this area and offer a vision for research in the near future.We hope this literature review will serve as a starting point for scholars and practitioners interested in learning about essential components of provenance,XAI,and TAI.

An explorative study on document type assignment of review articles in Web of Science,Scopus and journals’websites

Purpose:Accurately assigning the document type of review articles in citation index databases like Web of Science(WoS)and Scopus is important.This study aims to investigate the document type assignation of review articles in Web of Science,Scopus and Publisher’s websites on a large scale.Design/methodology/approach:27,616 papers from 160 journals from 10 review journal series indexed in SCI are analyzed.The document types of these papers labeled on journals’websites,and assigned by WoS and Scopus are retrieved and compared to determine the assigning accuracy and identify the possible reasons for wrongly assigning.For the document type labeled on the website,we further differentiate them into explicit review and implicit review based on whether the website directly indicates it is a review or not.Findings:Overall,WoS and Scopus performed similarly,with an average precision of about 99% and recall of about 80%.However,there were some differences between WoS and Scopus across different journal series and within the same journal series.The assigning accuracy of WoS and Scopus for implicit reviews dropped significantly,especially for Scopus.Research limitations:The document types we used as the gold standard were based on the journal websites’labeling which were not manually validated one by one.We only studied the labeling performance for review articles published during 2017-2018 in review journals.Whether this conclusion can be extended to review articles published in non-review journals and most current situation is not very clear.Practical implications:This study provides a reference for the accuracy of document type assigning of review articles in WoS and Scopus,and the identified pattern for assigning implicit reviews may be helpful to better labeling on websites,WoS and Scopus.Originality/value:This study investigated the assigning accuracy of document type of reviews and identified the some patterns of wrong assignments.

基于本体驱动的航空情报表格信息结构化研究

航空资料汇编是国际民航组织推荐的呈现各国航空信息的主要载体,其中以表格数据形式汇总了大量航空数据与航空运行限制信息。为实现航空汇编资料的智能查询,以及对航空资料汇编中静态数据的挖掘与利用,需要对航空汇编资料中的表格信息予以特征提取与结构化处理。将航空资料汇编中表格信息作为研究对象,提出了一种基于本体驱动的航空情报表格信息结构化抽取方法。首先构建航空情报领域信息的本体框架,实现对领域知识统一规范的描述;其次,利用Document AI对表格文档的布局结构进行研究与预处理,并利用随机森林算法与条件随机场模型进行特征实体提取验证与分析。实验结果表明,所提方法能够有效提取航空情报表格中的特征实体,为航空情报领域静态数据深入挖掘提供参考。

Hybrid Optimization Algorithm for Handwritten Document Enhancement

The Gannet Optimization Algorithm (GOA) and the Whale Optimization Algorithm (WOA) demonstrate strong performance;however, there remains room for improvement in convergence and practical applications. This study introduces a hybrid optimization algorithm, named the adaptive inertia weight whale optimization algorithm and gannet optimization algorithm (AIWGOA), which addresses challenges in enhancing handwritten documents. The hybrid strategy integrates the strengths of both algorithms, significantly enhancing their capabilities, whereas the adaptive parameter strategy mitigates the need for manual parameter setting. By amalgamating the hybrid strategy and parameter-adaptive approach, the Gannet Optimization Algorithm was refined to yield the AIWGOA. Through a performance analysis of the CEC2013 benchmark, the AIWGOA demonstrates notable advantages across various metrics. Subsequently, an evaluation index was employed to assess the enhanced handwritten documents and images, affirming the superior practical application of the AIWGOA compared with other algorithms.

Enhanced Topic-Aware Summarization Using Statistical Graph Neural Networks

The rapid expansion of online content and big data has precipitated an urgent need for efficient summarization techniques to swiftly comprehend vast textual documents without compromising their original integrity.Current approaches in Extractive Text Summarization(ETS)leverage the modeling of inter-sentence relationships,a task of paramount importance in producing coherent summaries.This study introduces an innovative model that integrates Graph Attention Networks(GATs)with Transformer-based Bidirectional Encoder Representa-tions from Transformers(BERT)and Latent Dirichlet Allocation(LDA),further enhanced by Term Frequency-Inverse Document Frequency(TF-IDF)values,to improve sentence selection by capturing comprehensive topical information.Our approach constructs a graph with nodes representing sentences,words,and topics,thereby elevating the interconnectivity and enabling a more refined understanding of text structures.This model is stretched to Multi-Document Summarization(MDS)from Single-Document Summarization,offering significant improvements over existing models such as THGS-GMM and Topic-GraphSum,as demonstrated by empirical evaluations on benchmark news datasets like Cable News Network(CNN)/Daily Mail(DM)and Multi-News.The results consistently demonstrate superior performance,showcasing the model’s robustness in handling complex summarization tasks across single and multi-document contexts.This research not only advances the integration of BERT and LDA within a GATs but also emphasizes our model’s capacity to effectively manage global information and adapt to diverse summarization challenges.

An Empirical Comparison Between Tutorials and Crowd Documentation of Application Programming Interface

API(application programming interface)documentation is critical for developers to learn APIs.However,it is unclear whether API documentation indeed improves the API learnability for developers.In this paper,we focus on two types of API documentation,i.e.,official API tutorials and API crowd documentation.First,we analyze API coverage and check API consistencies in API documentation based on the API traceability.Then,we conduct a survey and extract several characteristics to analyze which API documentation can help developers learn APIs.Our findings show that:1)API crowd documentation can be regarded as a supplement to the official API tutorials to some extent;2)the concerns for frequently-used APIs between different types of API documentation show a huge mismatch,which may prevent developers from deeply understanding the usages of APIs through only one type of API documentation;3)official API tutorials can help developers seek API information on a long page and API crowd documentation could provide long codes for a particular programming task.These findings may help developers select the suitable API documentation and find the useful information they need.

The inconsistency of documentation:a study of online C standard library documents

The C standard libraries are basic function libraries standardized by the C language.Programmers usually refer to their APl documentation provided by third-party websites.Unfortunately,these documents are not necessarily complete or accurate,especially for constraint sentences of APl usage,which are called Security Specifications(SSs).SS issues can prevent programmers from following obligatory constraints,which results in APl misuse vulnerabilities.Previous work studying SS issues could only find certain types of inaccurate SSs through checking the compliance between APl usage and existing SSs.Therefore,we propose a novel approach SSeeker for quickly discovering missing and inaccurate SSs through the inconsistency of semantically similar SSs.More specifically,SSeeker first completes broken sentences and discovers SSs from them by judging their constraint sentiment.Then SSeeker puts semantically similar SSs from different sources into a group,which can be used to discover missing or inaccurate SSs.With the help of SSeeker,we investigated 4 popular online third-party C standard library documents,studied their conformity with the C99 standard,analyzed their APls and SSs,and discovered 92 prototype issues,15 web page issues,and 96 SS issues.

An emotions-informed approach for digital documentation of rural heritage landscapes:Baojiatun,a traditional tunpu village in Guizhou,China

The application of digital technologies has greatly improved the efficiency of cultural heritage documentation and the diversity of heritage information.Yet the adequate incorporation of cultural,intangible,sensory or experimental elements of local heritage in the process of digital documentation,and the deepening of local community engagement,remain important issues in cultural heritage research.This paper examines the heritage landscape of tunpu people within the context of digital conservation efforts in China and the emergence of emotions studies as an evaluative tool.Using a range of data from the Ming-era village of Baojiatun in Guizhou Province,this paper tests an exploratory emotions-based approach and methodology,revealing shifting interpersonal relationships,experiential and praxiological engagement with the landscape,and emotional registers within tunpu culture and heritage management.The analysis articulates distinctive asset of emotional value at various scales and suggests that such approaches,applied within digital documentation contexts,can help researchers to identify multi-level heritage landscape values and their carriers.This methodology can provide more complete and dynamic inventories to guide digital survey and representation;and the emotions-based approach also supports the integration of disparate heritage aspects in a holistic understanding of the living landscape.Finally,the incorporation of community participation in the process of digital survey breaks down boundaries between experts and communities and leads to more culturally appropriate heritage records and representations.

Review of China’s information and documentation standardization work

China National Information and Documentation Standardization Technical Committee(SAC/TC4),founded in 1979,is the national technology standardization organization engaged in the field of information and documentation in China.Its institutional settings,scope and content of the work exactly correspond to the Information and Documentation Standardization Technical Committee of International Organization for Standardization(ISO/TC46).For 30 years,SAC/TC4 has always harmonized and organized national standardization work in accordance with the standard working system of ISO,established a clear standard constituting strategy and principles,set up an open mechanism for the standards development,promoted China’s information and document standardization,and obtained great achievements and valuable experiences.Following the rapid development of information and network technologies,standardization work in the field of international information and documentation is facing new challenges.SAC/TC4 also needs to cope with the situation by adopting a variety of strategies.