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. .

Documentation Concordance,Sharing and Utilization of Tea Germplasm Resources in Yunnan

In this paper,the research achievements and progress of Yunnan tea germplasm resource in past sixty years are systematically reviewed from the following aspects：exploration,collecting,conservation,protection,identification,evaluation and shared utilization.Simultaneously,the current problems and the suggestions about subsequent development of tea germplasm resources in Yunnan were discussed,including superior and rare germplasm collection,tea genetic diversity research,biotechnology utilization in tea germplasm innovation,super gene exploration and function,the construction of utilization platform,biological base of species and population conservation.

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.

Layered Documentation On the Process of Documenting Contemporary Dance and Physical Theatre

How can choreography and physical theatre pieces continue to perpetuate the work after rendering？ How to preserve their aura, their dynamics, and their ephemeral and genuine nature, as Walter Benjamin said？ In 1936, Benjamin already anticipated in The Work of Art in the Age of lts Technological Reproducibility that something is missing even in the best-finished reproduction. And memories of dance and physical theatre are intricate. The question is how to create a type of documentation that does not betray the vital flow of the event-based phenomenon. In this short article we will see a series of choreographic and performance artists like Esther Ferrer, Ayara Hern^indez Holz, and Olga de Soto who claimed a new form of organic documentation, making it turn performance or memory of viewers. Other creators as the company La Fura dels Baus claim documentation as spectacle and others on the opposite side, as Tino Sehgal propose radically non documentation of their work. Precisely, these different positions coincide with those of thinkers like Peggy Phelan, Sarah Bay-Cheng, or Paula Caspao who respect to a range of documentation and how it can never replace the live art.

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.

Compliance of Documentation Transfer Pricing Requirements in Foreign Direct Investment Enterprises in Vietnam

The increase of inter-boundary transactions brings a number of benefits for enterprises. However, even when benefits of transfer pricing are evident, multinational organizations still face legal challenges, including performing parts of transactions in another jurisdiction and motives of tax officials in investigating transfer pricing. This is especially true when countries do not want to lose benefits from tax collection. Therefore, many countries and organizations such as the Organization for Economic Cooperation and Development （OECD）, Pacific Association of Tax Administrators （PATA）, the European Union （EU）, and Vietnam have introduced requirements for transfer pricing documentation to prevent transfer pricing manipulation and maintain benefits from taxes. The aim of this research was to assess the compliance of those requirements of foreign direct investment （FDI） enterprises in Vietnam. This article which is a summary of our research includes the following sections： （1） OECD guidelines of transfer pricing documentation; （2） Vietnam regulations of transfer pricing documentation; （3） results of the research; and （4） discussion and conclusion.

Representation of residual stress symbol in the technical product documentation

A representation of residual stress graphic symbols in technical product documents is studied.The residual stress state of the product can be annotated in the technical product documents such as design drawings,process documents,test reports,papers and monographs.The composition of residual stress and the design of basic symbols,measurement method symbols,relief method symbols and state symbols of residual stress,and the representation of annotation for residual stress in documents are introduced.Residual stress symbol can be used in the design,manufacturing,inspection and service for the residual stress state requirements of the products in the mechanical manufacturing industry,as well as in light industry,daily necessities and other related industries.

A Framework Based on the DAO and NFT in Blockchain for Electronic Document Sharing

In the information age,electronic documents(e-documents)have become a popular alternative to paper documents due to their lower costs,higher dissemination rates,and ease of knowledge sharing.However,digital copyright infringements occur frequently due to the ease of copying,which not only infringes on the rights of creators but also weakens their creative enthusiasm.Therefore,it is crucial to establish an e-document sharing system that enforces copyright protection.However,the existing centralized system has outstanding vulnerabilities,and the plagiarism detection algorithm used cannot fully detect the context,semantics,style,and other factors of the text.Digital watermark technology is only used as a means of infringement tracing.This paper proposes a decentralized framework for e-document sharing based on decentralized autonomous organization(DAO)and non-fungible token(NFT)in blockchain.The use of blockchain as a distributed credit base resolves the vulnerabilities inherent in traditional centralized systems.The e-document evaluation and plagiarism detection mechanisms based on the DAO model effectively address challenges in comprehensive text information checks,thereby promoting the enhancement of e-document quality.The mechanism for protecting and circulating e-document copyrights using NFT technology ensures effective safeguarding of users’e-document copyrights and facilitates e-document sharing.Moreover,recognizing the security issues within the DAO governance mechanism,we introduce an innovative optimization solution.Through experimentation,we validate the enhanced security of the optimized governance mechanism,reducing manipulation risks by up to 51%.Additionally,by utilizing evolutionary game analysis to deduce the equilibrium strategies of the framework,we discovered that adjusting the reward and penalty parameters of the incentive mechanism motivates creators to generate superior quality and unique e-documents,while evaluators are more likely to engage in assessments.

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.

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.

Multimodal Deep Neural Networks for Digitized Document Classification

As digital technologies have advanced more rapidly,the number of paper documents recently converted into a digital format has exponentially increased.To respond to the urgent need to categorize the growing number of digitized documents,the classification of digitized documents in real time has been identified as the primary goal of our study.A paper classification is the first stage in automating document control and efficient knowledge discovery with no or little human involvement.Artificial intelligence methods such as Deep Learning are now combined with segmentation to study and interpret those traits,which were not conceivable ten years ago.Deep learning aids in comprehending input patterns so that object classes may be predicted.The segmentation process divides the input image into separate segments for a more thorough image study.This study proposes a deep learning-enabled framework for automated document classification,which can be implemented in higher education.To further this goal,a dataset was developed that includes seven categories:Diplomas,Personal documents,Journal of Accounting of higher education diplomas,Service letters,Orders,Production orders,and Student orders.Subsequently,a deep learning model based on Conv2D layers is proposed for the document classification process.In the final part of this research,the proposed model is evaluated and compared with other machine-learning techniques.The results demonstrate that the proposed deep learning model shows high results in document categorization overtaking the other machine learning models by reaching 94.84%,94.79%,94.62%,94.43%,94.07%in accuracy,precision,recall,F-score,and AUC-ROC,respectively.The achieved results prove that the proposed deep model is acceptable to use in practice as an assistant to an office worker.

Pre-training transformer with dual-branch context content module for table detection in document images

Background Document images such as statistical reports and scientific journals are widely used in information technology.Accurate detection of table areas in document images is an essential prerequisite for tasks such as information extraction.However,because of the diversity in the shapes and sizes of tables,existing table detection methods adapted from general object detection algorithms,have not yet achieved satisfactory results.Incorrect detection results might lead to the loss of critical information.Methods Therefore,we propose a novel end-to-end trainable deep network combined with a self-supervised pretraining transformer for feature extraction to minimize incorrect detections.To better deal with table areas of different shapes and sizes,we added a dualbranch context content attention module(DCCAM)to high-dimensional features to extract context content information,thereby enhancing the network's ability to learn shape features.For feature fusion at different scales,we replaced the original 3×3 convolution with a multilayer residual module,which contains enhanced gradient flow information to improve the feature representation and extraction capability.Results We evaluated our method on public document datasets and compared it with previous methods,which achieved state-of-the-art results in terms of evaluation metrics such as recall and F1-score.https://github.com/Yong Z-Lee/TD-DCCAM.

Research and Analysis of Grammatical Error Correction Technology for Chinese Documents

With the widespread use of Chinese globally, the number of Chinese learners has been increasing, leading to various grammatical errors among beginners. Additionally, as domestic efforts to develop industrial information grow, electronic documents have also proliferated. When dealing with numerous electronic documents and texts written by Chinese beginners, manually written texts often contain hidden grammatical errors, posing a significant challenge to traditional manual proofreading. Correcting these grammatical errors is crucial to ensure fluency and readability. However, certain special types of text grammar or logical errors can have a huge impact, and manually proofreading a large number of texts individually is clearly impractical. Consequently, research on text error correction techniques has garnered significant attention in recent years. The advent and advancement of deep learning have paved the way for sequence-to-sequence learning methods to be extensively applied to the task of text error correction. This paper presents a comprehensive analysis of Chinese text grammar error correction technology, elaborates on its current research status, discusses existing problems, proposes preliminary solutions, and conducts experiments using judicial documents as an example. The aim is to provide a feasible research approach for Chinese text error correction technology.