Calidad de los registros electrónicos de enfermería de un hospital de alta complejidad de la ciudad de Corrientes. Año 2021 / Quality of the electronic nursing records of a highly complex hospitalin the city of Corrientes. Year 2021

Introducción: hacer el registro de los cuidados que la Enfermería proporciona diariamente a los pacientes, es una tarea esencial, tanto para dar una adecuada calidad sanitaria como para el desarrollo de la profesión. Objetivo: identificar la calidad de los registros electrónicos de Enfermería de un hospital de alta complejidad de la ciudad de Corrientes. Metodología: se realizó un estudio cuantitativo de tipo descriptivo transversal donde se revisaron 133 historias clínicas digitales mediante una herramienta adaptada y previamente validada. Resultados: de forma específica, la variable identificación del paciente obtuvo calidad buena, en cuanto al registro de la valoración se identificó que el 92% de las historias clínicas registraron menos de 6 indicadores, una calidad deficiente, y el 8% restante registró calidad regular, y la variable intervenciones obtuvo una calidad deficiente con un 87% de registro de los indicadores. Conclusión: en los resultados de la investigación se llegó a la conclusión de que, la calidad de los registros electrónicos de enfermería del servicio de terapia intensiva del hospital es de calidad deficiente respecto al registro electrónico del proceso enfermero[AU]

Introduction: recording the care that nursing provides daily to patients is an essential task, both for providing adequate health quality and for the development of the profession. Objective:to identify the quality of the electronic nursing records of a highly complex hospital in the city of Corrientes. Methodology: a cross-sectional descriptive quantitative study was carried out where 133 digital medical records were reviewed using an adapted and previously validated tool. Results: specifically, the patient identification variable obtained good quality, regarding the assessment record, it was identified that 92% of the medical records re-gistered less than 6 indicators, a poor quality, and the remaining 8% re-gistered regular quality, and the variable interventions obtained a poorquality with 87% registering the indicators. Conclusion: in the results of the investigation, it was concluded that the quality of the electronic nursing records of the hospital's intensive care service is of poor quality compared to the electronic record of the nursing process[AU]

Introdução: registrar os cuidados que a enfermagem presta diaria-mente aos pacientes é tarefa essencial, tanto para a prestação de uma saúde de qualidade adequada, quanto para o desenvolvimento da profissão. Objetivo: identificar a qualidade dos registros eletrônicos de enfermagem de um hospital de alta complexidade da cidade de Corrientes. Metodologia: realizouse um estudo quantitativo descritivo transversal onde foram revistos 133 prontuários digitais por meio de um instrumento adaptado e previamente validado. Resultados: especificamente, a variável identificação do paciente obteve qualidade boa, quanto ao registro de avaliação, identificouse que 92% dos prontuários registraram menos de 6 indicadores, a qualidade ruim, e os 8% restantes registraram qualidade regular, e a variável as intervenções obtiveram uma qualidade ruim com 87% registrando os indicadores. Conclusão: nos resultados da investigação concluiuse que a qualidade do prontuário eletrônico de enfermagem do serviço de terapia intensiva do hospital é de baixa qualidade em relação ao prontuário eletrônico do processo de enfermagem[AU]

Primeros registros documentados y categorización del estado de conservación de Dressleria dodsoniana y Galeandra minax (Orchidaceae; Catasetinae) de Colombia

Registramos la presencia de Dressleria dodsoniana y Galeandra minax en Caquetá, Colombia, basados en dos poblaciones encontradas en la vertiente oriental de la Cordillera Oriental de los Andes y en el piedemonte Andino-Amazónico, respectivamente. Estas especies han sido previamente reportadas para el país en documentos impresos y en bases de datos, pero, sin la mención de ejemplares de herbario, siendo los registros fotográficos la única evidencia para su registro. Nuestros reportes resaltan la necesidad de confirmar la identidad y ocurrencia de las especies con la inclusión de colecciones botánicas en herbarios. Categorizamos ambas especies para Colombia como Críticamente Amenazadas (CR), debido principalmente, al deterioro de su hábitat y por el conocimiento de una única población registrada.

We document the presence of Dressleria dodsoniana and Galeandra minax in Caquetá, Colombia, based on two populations found in the eastern slope of the Eastern Cordillera of the Andes and in the Andean-Amazonian Piedmont, respectively. These species were previously reported in the country through printed documents and databases, but without herbarium specimens mentioned, with photographic records being the only evidence for their record. Our reports emphasize the need to confirm the identity and occurrence of the species by including botanical collections in herbaria. Both species are categorized as Critically Endangered (CR) in Colombia, primarily due to habitat deterioration and the knowledge of a single recorded population.

Cedrela domatifolia (Meliaceae), un nuevo registro de cedro para el Perú

Cedrela domatifolia W. Palacios es registrada por primera vez para Perú en el valle de Chanchamayo, departamento de Junín. Con esta adición se elevan a 11 especies del género Cedrela (Meliaceae) en el Perú. La característica vegetativa más resaltante de C. domatifolia son los domacios prominentes, situados en las axilas de los nervios secundarios de las láminas por el envés. En caracteres florales, los pétalos son de color rojo a fucsia, una característica no común en el género.

A new record of Cedrela domatifolia W. Palacios is presented in Chanchamayo Valley, department of Junin, which adds to 11 the number of Cedrela (Meliaceae) species recorded in Peru. The most notorious vegetative character of the species are the prominent domatia in the axils of the secondary nerves of blades. At floral characters, the petals are red to fuchsia, an uncommon feature in the genus.

Nuevo registro de Liolaemus warjantay (Reptilia, Liolaemidae) y comentarios sobre el grupo montanus en Perú

Se registra Liolaemus warjantay para el departamento de Ayacucho, una especie conocida anteriormente solo para Arequipa. La nueva población es identificada en base a secuencias de ADN y se muestra su variación morfométrica y merística. También, se realizan comentarios sobre las especies recientemente descritas del grupo montanus de Perú.

Liolaemus warjantay is recorded in the Ayacucho department, a species previously known only from Arequipa. The new population is identified based on DNA sequences, also its morphometric and meristic variability is presented. Additionally, comments are made regarding recently described species within the montanus group in Peru.

Nuevas localidades en la distribución de Corallus blombergi (Rendahl & Vestergren ,1941) (Reptilia: Squamata, Boidea), para Colombia

El género Corallus contiene serpientes esbeltas y arbóreas, que habitan en bosques tropicales y que presentan una amplia distribución; sin embargo, Corallus blombergi es una especie poco común en Colombia, con un número limitado de reportes. En este estudio se presenta el primer registro de C. blombergi para el departamento del Chocó, a partir de dos hembras, colectadas en zonas de bosque pluvial tropical, en los corregimientos de salero y Pacurita, convirtiéndose en la tercera y cuarta localidad donde se registra la presencia de esta especie. Los nuevos registros, amplían la distribución de la especie a 471,50 km, desde su último registro en Tumaco.

The corallus genus contains slender and arboreal snakes which inhabit tropical forests and have a wide distribution; however, Corallus blombergi is an uncommon specie in Colombia with a limited number of reports. This study presents the first record of C. blombergi for the department of Choco from two females, both collected in tropical rain forest areas, in the townships of Salero and Pacurita. becoming the third and fourth locality where the presence of this species is recorded. The new records extend the distribution of the species to 471.50 km since its last record in Tumaco.

Tendência temporal da prevalência e mortalidade infantil das anomalias congênitas no Brasil, de 2001 a 2018 / Temporal trends in prevalence and infant mortality of birth defects in Brazil, from 2001 to 2018

Resumo As anomalias congênitas (AC) configuram um relevante problema para a saúde pública global, afetando em média de 3% a 6% dos recém-nascidos em todo o mundo. No Brasil, ocupam a segunda posição entre os principais grupos de causas de óbito infantil. Assim, estudos amplos são necessários para mostrar o impacto das AC na saúde infantil. O presente estudo descreve a tendência temporal da prevalência e da mortalidade infantil por AC entre nascidos vivos (NV) no Brasil e em suas cinco regiões de 2001 a 2018, utilizando dados vinculados entre as bases de dados do Sistema de Informações sobre Nascidos Vivos (SINASC) e do Sistema de Informações sobre Mortalidade (SIM). A prevalência e mortalidade infantil por AC mostrou-se crescente no Brasil na maioria das regiões, principalmente no Norte e no Nordeste. Aquelas do aparelho osteomuscular foram as mais prevalentes ao nascimento (29,8/10.000 NV); as do aparelho circulatório passaram para a segunda posição (12,7/10.000 NV) após a vinculação das bases e representam a primeira causa de morte desse grupo. A técnica de vinculação de dados aplicada corrigiu a prevalência nacional das AC em 17,9% no período analisado, após serem recuperadas as AC notificadas no SIM, mostrando ser uma boa ferramenta para melhorar a qualidade das informações das AC.

Abstract Congenital anomalies (CA) are a relevant problem for global public health, affecting about 3% to 6% of newborns worldwide. In Brazil, these are the second main cause of infant mortality. Thus, extensive studies are needed to demonstrate the impact of these anomalies on births and deaths. The present study describes the temporal trends of prevalence and infant mortality due to CA among live births in Brazil and regions, from 2001 to 2018, using the related data between the Live Birth Information System (SINASC, acronym in Portuguese) and the Mortality Information System (SIM, acronym in Portuguese). The prevalence and infant mortality due to CA has increased in Brazil and in most regions, especially in the Northeast and North. CAs in the musculoskeletal system were the most frequent at birth (29.8/10,000 live births), followed by those in the circulatory system (12.7/10,000 live births), which represented the primary cause of death in this group. The applied linkage technique made it possible to correct the national prevalence of CA by 17.9% during the analyzed period, after retrieving the anomalies reported in SIM, thereby proving to be a good tool to improve the quality of information on anomalies in Brazil.

Primeros registros de Echiophis brunneus (Teleosteo; Ophichthidae) "anguila pecosa" en el norte del Perú

Echiophis brunneus, comúnmente conocida como anguila pecosa, es una especie bentónica costera de la familia Ophichthidae. Su distribución se reporta para el Pacífico Oriental desde el Golfo de California (EE. UU.) hasta el Golfo de Guayaquil (Ecuador). Se reporta por primera vez la presencia de E. brunneus en el norte del Perú a partir de tres ejemplares capturados. Así mismo se registra una nueva talla máxima para la especie y se adiciona la secuencia COI a la base de datos BoldSystems. Una de las principales características para su determinación fue la presencia del diente canino grande localizado en la zona distal del vómer. Las distancias genéticas entre E. brunneus con E. punctifer y E. intertinctus fueron de 0.087±0.013 y 0.095±0.014 respectivamente. Con este trabajo se amplía la distribución geográfica de E. brunneus hasta Salaverry (08°13'28"S, 78°59'22"W), así mismo sugerimos el posible establecimiento de una población de esta especie en la costa norte del Perú.

Echiophis brunneus, commonly known as fangjaw eel, is a coastal benthic species belonging to the Ophichthidae family. Its distribution is reported to be in the Eastern Pacific from the Gulf of California (USA) to the Gulf of Guayaquil (Ecuador). In this study, we report for the first time the presence of E. brunneus based on three specimens captured in northern Peru. Additionally, a new maximum size for the species is recorded, and the first COI sequence is added to the BoldSystems database. One of the main characteristics for its determination was the presence of a large canine tooth located in the distal area of the vomer. The genetic distances between E. brunneus with E. punctifer and E. intertinctus were 0.087±0.013 and 0.095±0.014 respectively. With this work the geographical distribution of E. brunneus is extended to Salaverry (08°13'28"S, 78°59'22"W). We also suggest the possible establishment of a population of this species on the northern coast of Peru.

An observational study of role of medical record department in tertiary care teaching hospital

Background: Medical record document explains all the details about the patient’s history, clinical findings, diagnostic test results, pre- and post-operative care, patient’s progress, and medication given. If written correctly, notes will support the doctor about the correctness of treatment. Aim and Objectives: Our objective was to study effectiveness and utility of medical record department at our medical college affiliated tertiary care institution. Materials and Methods: We did an observational study to determine various parameters of medical records such as consent, history and examination findings, pre-operative and intraoperative records, investigation documentation, nursing care chart, and concerned medical person’s signature. The study included 300 files. A medical record checklist was used as a tool for data collection. The study was conducted between January 2021 and January 2022. Data were collected, entered in Microsoft Excel spread sheet, and analyzed using percentage. Results: Out of the 300 files, 186 files belonged to different surgical specialties while the rest were of non-surgical fields. It was found that nursing assessment document was present in 78%, while discharged card copy was found attached in 75.33% files. Furthermore, surgical safety checklist was found in 89.24%, while signature of faculty was absent in 38.3% files. Conclusion: Medical record maintaining and keeping is an essential and vital part of health-care infrastructure, not only for data collection but also for calculating use of resources needed for better delivery of quality services to patients.

Implementação de Prontuário Eletrônico por profissionais médicos e enfermeiros da Atenção Primária à Saúde / Implementation of Electronic Medical Records by physicians and nurses in Primary Health Care

Objetivo: Avaliar a implementação o Prontuário Eletrônico do Cidadão da estratégia e-SUS na Atenção Primária a Saúde pelos médicos e enfermeiros de duas macrorregiões de saúde de Minas Gerais. Métodos: Estudo de método misto explanatório sequencial quanti-qualitativo. A coleta de dados ocorreu por meio de um formulário online. Foi construída uma matriz de análise e julgamento para avaliar e ponderar as questões avaliativas no instrumento de coleta. Resultados: De maneira geral, o grau de implementação de cada uma das funcionalidades (assistenciais e gerenciais) foi classificado como não adequado, mas há diferença quando se compara as profissões. Os dados mostram que a medicina quando comparada com a enfermagem tem a utilização do prontuário com escore menor, indicando que médicos informaram usar menos o prontuário eletrônico do que os enfermeiros. Conclusões: Apesar dos grandes esforços governamentais para expandir a implantação do prontuário eletrônico, sua implementação, de forma geral, ainda não é adequada. Dessa forma, a utilização do prontuário eletrônico como potencial qualificador de dados em saúde deve ser estimulada em direção à gestão e coordenação do cuidado(AU)

Objective: To evaluate the implementation of the Electronic Citizen's Record of the e-SUS strategy in Primary Health Care by physicians and nurses from two health macro-regions in Minas Gerais. Methods: Estudio de método mixto explicativo secuencial cuantitativo-cualitativo. Data collection took place through an online form. An analysis and judgment matrix were built to evaluate and weigh the evaluative questions in the collection instrument. Results: In general, the degree of implementation of each of the functionalities (assistance and management) was classified as not adequate, but there is a difference when comparing the professions. The data show that medicine, when compared to nursing, uses the medical record with a lower score, indicating that physicians reported using the electronic medical record less than nurses. Conclusions: Despite major government efforts to expand the implementation of electronic medical records, its implementation, in general, is still not adequate. Thus, the use of electronic medical records as a potential qualifier of health data should be encouraged towards the management and coordination of care(AU)

Objetivo: Evaluar la implementación del Registro Ciudadano Electrónico de la estrategia e-SUS en la Atención Primaria de Salud por médicos y enfermeros de dos macrorregiones de salud de Minas Gerais. Métodos: La recolección de datos se realizó a través de un formulario en línea, se construyó una matriz de análisis y juicio para evaluar y ponderar las preguntas evaluativas del instrumento de recolección. Resultados: En general, el grado de implantación de cada una de las funcionalidades (asistencia y gestión) fue catalogado como no adecuado, pero hay diferencias, al comparar las profesiones. Los datos muestran que la medicina, en comparación con la enfermería, utiliza la historia clínica con una puntuación más baja, lo que indica que los médicos utilizan menos la historia clínica electrónica que las enfermeras. Conclusiones: A pesar de los grandes esfuerzos gubernamentales por ampliar la implementación de la historia clínica electrónica, su implementación, en general aún no es adecuada. Por lo tanto, se debe fomentar el uso de la historia clínica electrónica como potencial calificador de datos de salud para la gestión y coordinación de la atención(AU)

Discrepancia anteroposterior en registro de relación céntrica con apoyo central intraoral en cubetas rodetes acrílicas (BOPAYACU) e inducción manual en adultos mayores desdentados totales / Anteroposterior discrepancy in centric relation record with intraoral central support in acylic impaction cups (BOPAYACU) and manual induction in edentulous older adults

Objetivo: Comparar la discrepancia anteroposterior medida a nivel de la platina incisiva de 2 métodos de registro intermaxilar en la misma sesión que la im-presión definitiva en adultos mayores desdentados totales. Materiales y métodos. Se incluyeron en el es-tudio 20 pacientes (n=20) con edad promedio de 70 años. En cada uno de ellos se obtuvieron registros intermaxilares con cubetas rodete de acrílico: uno con inducción manual (IM) y otro autoinducido con el sistema de cubeta rodete de acrílico y apoyo central único utilizando una superficie palatina de registro curva (BYC). Los modelos fueron montados en un ar-ticulador Whip Mix modelo 2240 al que se le adicio-nó un dispositivo de papel milimetrado, Orthodent, a nivel de la platina incisiva, para registrar las dife-rencias existentes entre las posiciones obtenidas. El análisis estadístico se llevó a cabo mediante el cálcu-lo de intervalos de confianza (95%) para las diferen-cias medias y prueba de t de student para datos apa-reados (nivel de significancia: α<0,05). Resultados. En el plano mesiodistal a nivel de la platina incisiva se encontró diferencia estadísticamente significativa entre las dos variables de registro (p<0,001). A este nivel el BYC proporcionó registros más retrusivos que IM. Media aritmética (desviaciones estándar) en milímetros: 3,82 (2,1). Conclusión. El sistema de re-gistro con cubetas rodete acrílicas y BYC incorpora-do a las mismas proporciona un registro intermaxi-lar más retrusivo que IM en adultos mayores des-dentados totales cuando se realizan dichos registros en la misma sesión que la impresión definitiva (AU)

Objective: To compare the anteroposterior discre-pancy measured at the level of the incisal plate of 2 methods of intermaxillary registration in the same session as the definitive impression in fully edentu-lous older adults. Materials and methods. Twenty pa-tients (n=20) with an average age of 70 years were included in the study. On each of them, intermaxillary recordings were obtained with acrylic rims trays: one with manual induction (MI) and the other with a self-induced system and single central support using a curved recording palatal surface (BYC). The models were mounted in a Whip Mix model 2240 articula-tor to which an Orthodent graph paper device was added, at the level of the incisal plate, to record the di-fferences between the positions obtained. Statistical analysis was carried out by calculating confidence intervals (95%) for mean differences and T-student for paired data (significance level: α<0.05). Results. On the mesiodistal plane at the level of the incisal plate, a statistically significant difference was found between the two recording variables (p<0.001). At this level the BYC provided more retrusive recordings than MI. Arithmetic mean (standard deviations) in mi-llimeters: 3.82 (2.1). Conclusions. The registration system with acrylic rim trays and BYC incorporated into them provides a more retrusive intermaxillary registration than MI in fully edentulous older adults when such registrations are made in the same ses-sion as the final impression.(AU)

Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system / Implementación de diagnósticos de enfermería intraoperatorios y postoperatorios inmediatos en el sistema de gestión informatizado / Implementação dos diagnósticos de enfermagem do transoperatório e pós-operatório imediato no sistema de gestão informatizado

ABSTRACT Objective: To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA International taxonomy. Method: Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare. Results: For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining "who, what, when, and where". The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods. Conclusion: The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care.

RESUMEN Objetivo: Implementar, en un software de manejo de la salud, registros electrónicos del proceso de enfermería perioperatorio y la etapa de diagnósticos de enfermería transoperatorios y postoperatorios inmediatos, con base en la taxonomía NANDA internacional. Método: Informe de experiencia realizado a partir de la consecución del ciclo Plan-Do-Study-Act), que permite planificar la mejora con un propósito más claro, dirigiendo cada etapa. Este estudio fue realizado en un complejo hospitalario en el sur de Brasil, utilizando el Software Tasy/Philips Healthcare. Resultados: Para la inclusión de diagnósticos de enfermería, se concluíran tres ciclos, se estableceran predicciones de los resultados esperados, y se asignaron tareas, definiendo "quién, qué, cuándo y dónde". El modelo estructurado contempló siete posibles aspectos, 92 signos y síntomas para ser evaluados y 15 diagnósticos de enfermería para ser utilizados en el transperatorio y postoperatorio inmediato. Conclusión: El estudio permitió implementar, en un software de manejo de la salud, registros electrónicos del proceso de enfermería perioperatorio, que comprende diagnósticos de enfermería transoperatoria y postoperatoria inmediata, además de los cuidados de enfermería.

RESUMO Objetivo: Implementar, em um software de gestão em saúde, os registros eletrônicos do processo de enfermagem perioperatório e a etapa de diagnósticos de enfermagem transoperatório e pós-operatório imediato, fundamentados na taxonomia NANDA International. Método: Relato de experiência conduzido a partir da realização do ciclo PDSA (Plan-Do-Study-Act), o qual permite o planejamento de melhoria com um propósito mais claro, direcionando cada etapa. Este estudo foi realizado em um complexo hospitalar da região sul do Brasil, utilizando o software Tasy/Philips Healthcare. Resultados: Para a inclusão dos diagnósticos de enfermagem, rodaram-se três ciclos, estabeleceram-se previsões de resultados esperados, e as tarefas foram atribuídas, definindo "quem, o quê, quando e onde". O modelo estruturado contemplou sete possibilidades de aspectos, 92 sinais e sintomas a serem avaliados e 15 diagnósticos de enfermagem para serem utilizados no transoperatório e pós-operatório imediato. Conclusão: O estudo possibilitou implementar, em um software de gestão em saúde, os registros eletrônicos do processo de enfermagem perioperatório, compreendendo diagnósticos de enfermagem do transoperatório e pós-operatório imediato, além de cuidados de enfermagem.

Audit of dental record-keeping at a university dental hospital

Background: Good record-keeping is fundamental in clinical practice and essential for practising dental practitioners and those in training. Aim: This study aimed to evaluate the level of compliance with clinical record-keeping by undergraduate dental students and staff at a university dental hospital. Setting: The selected study setting was the Admissions and Emergency section at a university dental hospital. Methods: A retrospective, cross-sectional review was undertaken of 257 clinical records. The CRABEL scoring system was used to evaluate 12 variables. The 12 variables included: patient name, patient hospital number, date of examination, patient main complaint, medical history, dental history, proposed treatment, proposed procedure for next visit, patient consent signature, treatment and treatment codes, student name and signature, clinical supervisor name and signature. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level. Results: The median CRABEL score was 87 and interquartile range (IQR: 70­92). A CRABEL score of 100 was achieved by the students in the variable patient main complaint, indicating a 100% compliance with this variable. Other variables such as signature of supervisors showed poor compliance. The CRABEL scores showed no statistically significant difference (p = 0.86) between the students and clinical supervisors. Conclusion: The overall audit showed that there was poor compliance with record-keeping. Contribution: The study highlights the importance of good record keepings so that key information can be accessed for proper diagnosis and treatment of the patient. An electronic filing system presents an alternative manner of documenting medical records.

Practice of structured electronic medical record design and quality management / 中华医院管理杂志

In order to assist in the standardization and maturity evaluation of national hospital information interconnection, and further standardize the application and management of hospital medical record data, a hospital carried out the practice of design of structured medical records and the corresponding quality management from April 2021. Based on the six sigma quality management method, the hospital had developed universal templates for electronic medical records and a list of candidate electronic medical record templates. The problems faced by medical record data had been analyzed, and improvement strategies had been proposed from three levels: template design, software functionality and management services. The clinical departments were guided to design and develop various structured electronic medical record templates for specialties and specialized diseases, and established a medical record template design and quality management method. The hospital had ultimately designed a total of 614 structured electronic medical record templates that met the actual needs of the hospital. This practice enhanced the scalability of structured templates and quality of the data, and achieved localization and specialization of medical record templates while meeting the requirements of information interconnection and sharing, providing reference for promoting the interconnection and sharing of electronic medical records of hospitals in China.

Construction of an electronic medical record sharing convenience service platform based on blockchain / 中华医院管理杂志

Blockchain technology has the advantages of decentralization, secure sharing and tamper resistance, and high privacy, which can solve the current problem of sharing electronic medical records in medical institutions in China. A tertiary hospital established an electronic medical record sharing services convenience service platform based on blockchain in collaboration with China mobile gansu company in September 2021. The hardware architecture of the platform consisted of a hospital data warehouse, a local front-end computer and a blockchain platform. The functional architecture included platform front-end services, the blockchain electronic medical record archiving and service platform. The technical architecture included the underlying blockchain, service layer, interface layer and application layer, which was embedded with asymmetric encryption technology, hash algorithm, smart contract and other technical means, ensuring data ownership and on-demand, controllable, real-time and secure sharing of data. Since the operation of the platform in September 2021, as of October 2022, a tertiary hospital had accumulated 21 545 patient medical records on the chain. The overall operation of the platform was smooth, achieving reliable storage and secure sharing of patient electronic medical records, providing reference for further promoting the interconnection trusted sharing of electronic medical records in medical institutions in China.

Construction and effectiveness evaluation of surgical complication monitoring mode based on medical record homepage data / 中华医院管理杂志

Objective:To explore the establishment of a surgical complication monitoring mode based on data on the medical record homepage, and analyze its impact on the trend of changes in surgical complication incidence.Methods:A monitoring mode of surgical complication was developed based on the " structure-process-results" framework by using surgical complication rates derived from performance appraisal for a tertiary general hospital in Guangzhou. The number of surgical complications and the number of discharged surgical patients was collected from the hospital from January 2019 to June 2022 through the home page collection system for performance appraisal of national tertiary public hospitals. Descriptive analysis was used to analyze the incidence of surgical complications, and Joinpoint regression was used to analyze the trend of changes in the incidence of surgical complications. Monthly percentage change ( MPC) and average monthly percentage change ( AMPC) were calculated. Results:Since the hospital began implementing the surgical complication monitoring mode in May 2021, the incidence of surgical complications had decreased from 2.55% in June 2021 to 0.82% in June 2022, with an MPC of -5.58% ( P=0.024), which was better than the changes from January 2019 to May 2021 ( MPC=0.18%, P=0.755). Conclusions:The surgical complication monitoring mode constructed by the hospital can effectively reduce the incidence of surgical complications, providing reference for optimizing hospital′s medical quality management process and decision-making mode.

Analysis of disease characteristics and hospitalization burden of elderly patients with cerebrovascular disease based on home page of medical records / 中华老年医学杂志

Objective:To analyze the disease characteristics and hospitalization burden of elderly inpatients with cerebrovascular disease, so as to provide basis for disease prevention, diagnosis, treatment and rehabilitation of elderly patients with multiple chronic conditions.Methods:The data of the first page of medical records of elderly inpatients with cerebrovascular disease from 2015 to 2020 in a comprehensive tertiary hospital in Jiangsu Province were retrospectively collected.Descriptive analysis, variance analysis and multiple linear regression analysis were carried out for the research objects using SPSS statistics and Python complex network methods.Results:A total of 14 657 elderly inpatients with cerebrovascular disease were included.From 2015 to 2020, the number of hospitalizations increased from 1 268 to 4 733, the average number of hospitalizations increased from 2.0 to 2.9, the average length of stay decreased from 11.9 days to 9.1 days, and the average number of illnesses increased from 1.9 to 4.9.The five most common comorbidities associated with cerebrovascular diseases were hypertension, diabetes, ischemic heart disease, other types of heart disease and other respiratory diseases.From 2015 to 2020, the average hospitalization costs of elderly cerebrovascular inpatients decreased from 20588.1 Chinese yuan(CYN)to 15580.9 Chinese yuan(CYN). The hospitalization cost was mainly composed of drug cost(46.6%), diagnosis cost(28.2%)and treatment cost(20.2%). There were significant differences in the average hospitalization expenses among patients with different gender, age, number of admissions, length of stay and number of diseases( P<0.05 for all). Gender, age, number of hospitalizations and length of stay had an impact on hospitalization expenses. Conclusions:The number of inpatients, comorbidities, and hospitalized times of elderly patients with cerebrovascular disease showed an increasing trend, while the number of hospitalization days and the average hospitalization cost showed a downward trend.Comorbidities associated with cerebrovascular diseases should be one of the concerns of chronic disease management in the elderly.

Analysis on the medication rules of Pu Ji Fang for treating acne externally based on data mining / 国际中医中药杂志

Objective:To analyze the medication rules in the ancient book Pu Ji Fang for the external treatment of acne based on data mining method. Methods:By screening out the methods of treating acne externally in Pu Ji Fang and establishing a standardized medical record database, this paper adopted the web version of Ancient and Modern Medical Record Cloud Platform to calculate the frequency, properties, flavors, and meridians of those medicines, and conduct cluster analysis by using IBM SPSS Modeler 18.0 software to analyze the association rules. Results:A total of 87 prescriptions were selected, including 164 kinds of Chinese materia medica, among which. Radix Angelicae, Ligusticum Wallichii, Rhizoma Typhoni and lead powder are frequently appeared. The properties of those medicines are mainly warm, cold and mild; the flavors of those medicines are mainly spicy, acrid, sweet and bitter, and the meridians mainly belongs to lung, spleen, stomach and liver meridians. The medical pair and group with the strongest associationion are Ligusticum Wallichii- Radix Angelicae and Rhizoma Typhonii- Radix Angelicae- Ligusticum Wallichii. Those freuently appeared medicines could be grouped into three categories. The paste dosage that was frequently appeared has strong correlation with tallow, mercury and lead powder, while the powder dosage that was frequenctly appeared has strong correlation with Angelica Dahurica, Radix Saponicae, Gleditsia sinensis, Radices Ligustici Sinensis and Ligusticum Wallichii. Conclusions:The application of data mining method could preliminarily reveal the medication rules of Pu Ji Fang for the external treatment of acne. The main treatment method is XinSanFaYue. The three categories of Chinese materia medica are used to treat the syndrome of asthenic habitus attacked by exogenous pathogenic factors, exterior attacked by wind heat and hot blood stasis respectively, showing the rules of treating acne externally before Ming Dynasty and providing references for the clinical treatment of acne.

Analysis and optimization of the record management practice in occupational health examination institutions / 中国职业医学

The Prevention and Control of Occupational Diseases Law revised in 2017 abolished the qualification test and approval for occupational health examination institutions, and replaced it with record management. The record does not belong to any type of administrative permit and does not require the premise of “general prohibition”. Its core idea is that “the public law actively acts as an obligation”, which does not prohibit administrative counterpart from carrying out specific tasks, mainly information collection, supervision and management of follow-ups, and emphasizes on simplifying procedures, improving working efficiency and stimulating market vitality. It is a strategic measure of the government's reform on “release, control and service”. It has the functional significance of alleviating information asymmetry, cultivating market credit mechanism and reflecting the government's flexible supervision and management mechanisms. However, China has not yet unified legislation on record management, and individuals on the theoretical and practical circles have different understandings on the concept, operation principle, and management effectiveness of the record management. There are practical dilemmas in the record management of occupational health examination institutions, such as alienation of record management into licensing, insufficient regulation of record management procedures, and weak in-process and post-process supervision and management capabilities. It is suggested to clarify the legal nature of record management, unify and improve the record management procedures, and improve in-process and post-process supervision and management capabilities. By building a legal, scientific and systematic regulation for the record management of occupational health examination institutions, adhering to the unity of “discharge” and “control”, it could effectively safeguard the legitimate rights and interests of occupational health examination institutions, workers and employers.

Construction and application of an intelligent injury monitoring system in Yinzhou District / 预防医学

@#Injury monitoring is an important approach for injury control and is an important part of comprehensive disease monitoring. With the development of medical digitalization, an intelligent injury monitoring system has been created in Yinzhou District, Ningbo City, Zhejiang Province using artificial intelligence techniques based on Ningbo Municipal Health Information Platform and has been applied across the district since 2019. The manual card-reporting mode has been transformed to intelligent card-reporting mode in this system, which achieves functions of epidemiological analyses of the monitoring data, early warning of high-incidence injuries, classified management of injury and quality control of report cards. Nearly 300 thousand cards have been automatically reported since the system was online available since November 2022, and the epidemiological characteristics of injury were preliminarily understood, which provide data supports to early earning and interventions of injury. The intelligent injury monitoring system greatly improves the injury monitoring efficiency and card-reporting quality, and saves a large number of manpower and material resources, which provides a powerful technical support to widespread injury monitoring.

Optimization of quality assessment system of clinical blood transfusion records / 中国输血杂志

【Objective】 To determine the value of quality assessment system in supervising standard clinical blood use and improving the quality of clinical blood transfusion medical records. 【Methods】 The clinical blood transfusion records of Children′s Hospital, Zhejiang University School of Medical every quarter from January 2019 to December 2022 were selected and extracted for evaluation by 5% to 10% for the current season. These blood transfusion medical records were scored and graded A(≥90 points)/B(80-89 points)/C(<80 points)according to the Evaluation Table of Clinical Science Rational Use of Blood in Children′s Hospital of Zhejiang University, and the annual A rate was statistically analyzed. After summarizing the deduction points, a rectification plan was submitted to the medical department and publicized on the hospital network. 【Results】 A total of 1 975 blood transfusion medical records were analyzed from January 2019 to December 2022, including 343 in 2019 (17.37%), 517 in 2020 (26.18%), 556 in 2021 (28.15%) and 559 in 2022 (28.30%), with Grade A rates at 67.06%, 92.07%, 93.17% and 91.06%, respectively. According to Pearson Chi-square test, the Grade A rates of blood transfusion records in 2020, 2021 and 2022 were significantly higher than those in 2019 (P<0.000 1). In the assessment, the main reasons for deduction of points were missed pre-transfusion immunization tests and missed blood transfusion course records. From 2019 to 2022, the missed rates of pre-transfusion immunization tests were 22.68%, 6.47%, 1.26% and 2.49%, and the missed rates of blood transfusion course records were 32.21%, 10.59%, 5.57% and 6.61%, respectively. 【Conclusion】 The regular and reasonable assessment and publicity system of blood transfusion medical records is conducive to improving the quality of blood transfusion medical records, promoting rational blood use and ensuring the safety of blood use for children.