Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record

Salazar, Luis; Best, Thomas M.; Hiestand, Brian

doi:10.1016/j.ajem.2010.05.012

Cited by 12 publications

(12 citation statements)

References 18 publications

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“…Incompleteness of information in medical history records is rather common. 22 Another potential limitation is the hospital-based character of the study. The control patients also had been referred to the departments of Oral Maxillofacial Surgery for specific diseases, such as oral malignancies and Sjögren syndrome.…”

Section: Discussionmentioning

confidence: 99%

Systemic diseases and the risk of developing salivary stones: a case control study

Kraaij

Karagozoglu

Kenter

et al. 2015

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

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Section: Discussionmentioning

confidence: 99%

Systemic diseases and the risk of developing salivary stones: a case control study

Kraaij

Karagozoglu

Kenter

et al. 2015

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

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“…Determining when imaging is appropriate however is challenging, and there are many barriers to reducing the inappropriate use of imaging such as fear of missing an important diagnosis and patient expectations. To illustrate the inappropriate use of imaging, foot and ankle radiographs are ordered in 70%-95% of ankle injury cases in emergency departments, 15,16 but less than 20% present with a fracture. 16 Validated decision rules can help clinicians (particularly inexperienced or junior clinicians) identify the need for imaging in patients with a suspected fracture and reduce the use of low-value imaging.…”

Section: Imagingmentioning

confidence: 99%

High‐ and low‐value care in sport and exercise medicine: Areas for consideration

2020

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High‐value care and low‐value care are concepts failing to receive attention in sport and exercise medicine. High‐value care refers to an intervention that provides a benefit or where the probable benefit exceeds the risk of harm. Low‐value care refers to an intervention that provides little‐to‐no benefit or where the risk of harm exceeds the probable benefit. To start the conversation, we apply the concepts of high‐ and low‐value care to the use of imaging, opioids, injections, surgery, and exercise therapy in sport and exercise medicine. We conclude with suggestions to help sport and exercise medicine clinicians replace low‐value care with high‐value care. In summary: (a) Only order imaging if you suspect findings that will positively guide the direction of treatment; (b) To reduce opioid use, ensure an adequate trial of non‐pharmacological and non‐opioid treatments; (c) Only provide injections when an adequate trial of non‐pharmacological treatments has failed, and the short‐term benefits outweigh the risk of long‐term harms; (d) Consider initial non‐surgical management for cases where evidence suggests early surgery is not necessary (eg, anterior cruciate ligament tears); and (e) Promote independence with exercise therapy (instead of extensive supervision) when feasible, acceptable, and evidence suggests it has equivalent outcomes (eg, post‐surgery).

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“…Over the past decade, systems such as electronic medical records (EMR) and electronic health records (EHR) have been used in many countries to facilitate the documentation of medical care (Burke et al , 2015; D’huyvetter et al , 2014). However, these systems do not continually improve the quality of the documentation (Hahn et al , 2011; Salazar et al , 2011; Lemma et al , 2020). Methods used to eliminate possible data deficiency and enhance EMR include data quality assessment (DQA) guidelines (Weiskopf et al , 2017; Callahan et al , 2017; WHO, 2017), audit and feedback, reminders, dictation, training, templates and multiple interventions (Lorenzetti et al , 2018; Triplet et al , 2017).…”

Section: Introductionmentioning

confidence: 99%

Determining the requirements of a medical records electronic deficiency management system: a mixed-method study

Salmanizadeh

Ameri

Ahmadian

et al. 2022

RMJ

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Purpose Despite the presence of electronic medical records systems, traditional paper-based methods are often used in many countries to document data and eliminate medical record deficiencies. These methods waste patient and hospital resources. The purpose of this study is to evaluate the traditional deficiency management system and determine the requirements of an electronic deficiency management system in settings that currently use paper records alongside electronic hospital information systems. Design/methodology/approach This mixed-method study was performed in three phases. First, the traditional process of medical records deficiency management was qualitatively evaluated. Second, the accuracy of identifying deficiencies by the traditional and redesigned checklists was compared. Third, the requirements for an electronic deficiency management system were discussed in focus group sessions. Findings Problems in the traditional system include inadequate guidelines, incomplete procedures for evaluating sheets and subsequent delays in activities. Problems also included the omission of some vital data elements and a lack of feedback about the documentation deficiencies of each documenter. There was a significant difference between the mean number of deficiencies identified by traditional and redesigned checklists (p < 0.0001). The authors proposed an electronic deficiency management system based on redesigned checklists with improved functionalities such as discriminating deficiencies based on the documenter’s role, providing systematic feedback and generating automatic reports. Originality/value Previous studies only examined the positive effect of audit and feedback methods to enhance the documentation of data elements in electronic and paper medical records. The authors propose an electronic deficiency management system for medical records to solve those problems. Health-care policymakers, hospital managers and health information systems developers can use the proposed system to manage deficiencies and improve medical records documentation.

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Incomplete documentation of elements of Ottawa Ankle Rules despite an electronic medical record

Cited by 12 publications

References 18 publications

Systemic diseases and the risk of developing salivary stones: a case control study

Systemic diseases and the risk of developing salivary stones: a case control study

High‐ and low‐value care in sport and exercise medicine: Areas for consideration

Determining the requirements of a medical records electronic deficiency management system: a mixed-method study

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