2.50
Hdl Handle:
http://hdl.handle.net/10755/166352
Category:
Abstract
Type:
Presentation
Title:
Analysis of Injury Description in the Medical Record
Author(s):
Sapnas, Kathryn; Toledo, J.
Author Details:
Kathryn Sapnas, PhD, Assistant Professor, University of Miami, Coral Gables, Florida, USA, email: ksapnas@miami.edu; J. Toledo
Abstract:
The accurate and precise documentation of a patient's injuries is critical in the appropriate treatment of the trauma patient. The medical record is the central location for the dialogue regarding the description, diagnosis, and treatment plan of the patient. At the present time there is no unified language, descriptive terminology, or methodology that can be used by providers to document or quantify injury description. Currently there is no central organization or conceptual framework for the presentation of the data in the medical record. The paper medical record in its present state reflects a melange of terminology and presentation formates related to the documentation of an medical problems, diagnoses, and virtual diagnoses of teh patient. This lack of organization and scientific logic in the presentation of medical data obviates the problem of injury description. It also prohibits precision, accuracy, and quantification of injury with other variables such as AID, CPT, DRG, ICD9, RVS, and supplies. The purpose of this study is to examine the medical record of traume patients and to document the verbatim descriptions of teh traumatic injuries in the medical record by all providers, to assess the accuracy and precision in that documentation, and to connect the dimensions of accuracy, precision, and timeliness as they occur throughout the patient's hospitalization. This pilot study is part of a parallel multidisciplinary field study. A non-probability sample of 20 trauma patients enrolled in teh CRASH Study was obtained. The sampling site was an urban free standing Level I Trauma Center. The anmes of patients were obtained from teh computerized CARE System database. The multimedia CRASH Study summary document provided the expert diagnoses. A spreadsheet format was employed in the data collection. The verbatim injury descriptions were transcribed, chronologized, and placed in categories specific to anatomic regions. This analysis of patient injuries facilitated the post hoc reconstruction of the patient's injuries from those verbatim descriptions presented in the chart by providers. The data were analyzed using descriptive statistics. The descritpion of teh present medical record and injury documentation has identified many variances. Variations of teh terms used have been noted based on the time of injury, type of care provider and service affiliation, as well as the level of abstraction or concreteness of teh description. The changes in the characterization of teh patient injuries as they occur through time, in all degrees through provider dialogue in the medical record serves to connect the multiple dimensions of injury. The progression to a common language of injury description can provide many potential benefits in the areas of health care education, practice, research, and administration. A unified nomenclature for injury description will give rise to the development of a taxonomy. There is a multifaceted potential that may be realized by the ability to accurately and consistently describe the patient's injuries. The need to develop a lexicon of injury and a method appropriate to quantify injury will enable verification, validation, and reliability, as well as precision and accuracy of the injury description.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
Feb 29 - Mar 2, 1996
Conference Host:
Southern Nursing Research Society
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleAnalysis of Injury Description in the Medical Recorden_GB
dc.contributor.authorSapnas, Kathrynen_US
dc.contributor.authorToledo, J.en_US
dc.author.detailsKathryn Sapnas, PhD, Assistant Professor, University of Miami, Coral Gables, Florida, USA, email: ksapnas@miami.edu; J. Toledoen_US
dc.identifier.urihttp://hdl.handle.net/10755/166352-
dc.description.abstractThe accurate and precise documentation of a patient's injuries is critical in the appropriate treatment of the trauma patient. The medical record is the central location for the dialogue regarding the description, diagnosis, and treatment plan of the patient. At the present time there is no unified language, descriptive terminology, or methodology that can be used by providers to document or quantify injury description. Currently there is no central organization or conceptual framework for the presentation of the data in the medical record. The paper medical record in its present state reflects a melange of terminology and presentation formates related to the documentation of an medical problems, diagnoses, and virtual diagnoses of teh patient. This lack of organization and scientific logic in the presentation of medical data obviates the problem of injury description. It also prohibits precision, accuracy, and quantification of injury with other variables such as AID, CPT, DRG, ICD9, RVS, and supplies. The purpose of this study is to examine the medical record of traume patients and to document the verbatim descriptions of teh traumatic injuries in the medical record by all providers, to assess the accuracy and precision in that documentation, and to connect the dimensions of accuracy, precision, and timeliness as they occur throughout the patient's hospitalization. This pilot study is part of a parallel multidisciplinary field study. A non-probability sample of 20 trauma patients enrolled in teh CRASH Study was obtained. The sampling site was an urban free standing Level I Trauma Center. The anmes of patients were obtained from teh computerized CARE System database. The multimedia CRASH Study summary document provided the expert diagnoses. A spreadsheet format was employed in the data collection. The verbatim injury descriptions were transcribed, chronologized, and placed in categories specific to anatomic regions. This analysis of patient injuries facilitated the post hoc reconstruction of the patient's injuries from those verbatim descriptions presented in the chart by providers. The data were analyzed using descriptive statistics. The descritpion of teh present medical record and injury documentation has identified many variances. Variations of teh terms used have been noted based on the time of injury, type of care provider and service affiliation, as well as the level of abstraction or concreteness of teh description. The changes in the characterization of teh patient injuries as they occur through time, in all degrees through provider dialogue in the medical record serves to connect the multiple dimensions of injury. The progression to a common language of injury description can provide many potential benefits in the areas of health care education, practice, research, and administration. A unified nomenclature for injury description will give rise to the development of a taxonomy. There is a multifaceted potential that may be realized by the ability to accurately and consistently describe the patient's injuries. The need to develop a lexicon of injury and a method appropriate to quantify injury will enable verification, validation, and reliability, as well as precision and accuracy of the injury description.en_GB
dc.date.available2011-10-27T14:45:28Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T14:45:28Z-
dc.conference.dateFeb 29 - Mar 2, 1996en_US
dc.conference.hostSouthern Nursing Research Societyen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.-
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