Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 4 de 4
Filter
1.
World Neurosurg ; 148: e667-e673, 2021 04.
Article in English | MEDLINE | ID: mdl-33497824

ABSTRACT

BACKGROUND: Documentation is the cornerstone of good patient care and vital to proper coding and billing. Consistent and standardized documentation improves communication among physicians and can lead to better reimbursement. By understanding which elements in the neurosurgery history and physical examination are omitted the most often and the effects on the coding level, institutional-specific solutions can be implemented. METHODS: We performed a retrospective study of neurosurgical patients at a single academic institution who undergone a neurosurgery history and physical examination for an initial inpatient admission from July 2015 to July 2016. The data collected included documentation type (typed, dictated, dynamic documentation without a template, neurosurgery history and physical examination template [NHPT]) and ultimate coding level (1, 2, or 3) determined by a review by a professional coder. RESULTS: A total of 609 notes were reviewed. Of the 609 notes, 88 (14.4%) were missing an element of documentation. The most common missing element was the physical examination (40 of 88; 45.5%), followed by a combination (27 of 88; 30.7%), review of systems (14 of 88; 15.9%), and medical, family, and/or social history (7 of 88; 8.0%). The dynamic documentation without template notes had the highest percentage of missing elements (49 of 96; 51.0%), followed by the typed notes (7 of 49; 14.3%) and dictated notes (30 of 268; 11.2%) compared with the NHPT notes (2 of 196; 1.0%). CONCLUSION: The most common missing elements for inpatient neurosurgery documentation were the review of systems and physical examination. The documents with the highest percentage of missing elements were those that used dynamic documentation without a template. We recommend implementing a dedicated NHPT to improve capturing these elements for improved clinical documentation. Such changes could also improve the coding level and subsequent reimbursement.


Subject(s)
Documentation/statistics & numerical data , Insurance, Health, Reimbursement/statistics & numerical data , Medical History Taking/methods , Neurosurgical Procedures/methods , Physical Examination/methods , Electronic Health Records , Humans , Reference Standards , Retrospective Studies
2.
J Public Health Manag Pract ; 23(6): 614-617, 2017.
Article in English | MEDLINE | ID: mdl-27997483

ABSTRACT

Familial Creutzfeldt-Jakob disease (fCJD) results from inheritance of mutations in the prion protein gene. Confirming fCJD diagnosis is essential for informing persons of their potential hereditary risk and for genetic counseling to support personal decisions for genetic testing and family planning. We describe a case of fCJD that was linked to a large cluster of African Americans with fCJD identified through a public health investigation, including 8 confirmed cases and 13 suspected cases involving 7 generations in 1 family. Genetic counseling is an important component of fCJD management for families coping with genetic prion diseases.


Subject(s)
Black or African American/genetics , Cluster Analysis , Creutzfeldt-Jakob Syndrome/diagnosis , Genetic Testing/methods , Humans , Prions/genetics , Public Health/methods , United States
3.
Arch Intern Med ; 170(18): 1656-63, 2010 Oct 11.
Article in English | MEDLINE | ID: mdl-20937925

ABSTRACT

BACKGROUND: In August 2008, the largest known US serotype 1 Escherichia coli O111 outbreak occurred in Oklahoma, causing 341 illnesses, including hemolytic uremic syndrome (HUS). HUS is not well described in non-O157 E coli outbreaks but occurs in 2% to 15% of O157 infections, predominantly among children. We examined outbreak-related hospitalizations to characterize E coli O111 illness, the HUS attack rate, and factors associated with subsequent HUS diagnosis among hospitalized patients. METHODS: Medical records were reviewed for clinical presentation and evidence of HUS among hospitalized patients identified during the outbreak investigation. Characteristics of hospitalized patients with vs without HUS were compared. RESULTS: HUS was identified in 26 of 156 (16.7%) confirmed or probable E coli O111 infections; 65.4% of patients with HUS required dialysis, and 1 patient died. The median age of patients with HUS was 43.5 years (age range, 1-88 years); adults composed 57.7% of HUS cases. Characteristics at hospital admission associated with subsequent HUS diagnosis included white blood cell count of at least 20 000/µL (adjusted odds ratio [aOR], 11.3; 95% confidence interval [CI], 1.7-75.3), elevated serum creatinine level for age (9.7; 1.4-69.2), and vomiting before hospital admission (6.8; 1.5-31.3). Administration of antimicrobial agents (risk ratio [RR], 1.0; 95% CI, 0.5-1.8) or medication with antimotility effects (1.4; 0.6-2.9) was not associated with subsequent HUS. CONCLUSIONS: The HUS attack rate in this E coli O111 outbreak was comparable to that for E coli O157-related illnesses, but most cases occurred among adults. On admission, factors associated with subsequent HUS can identify patients who require close monitoring and early aggressive supportive care to improve outcomes.


Subject(s)
Escherichia coli Infections/complications , Escherichia coli Infections/epidemiology , Escherichia coli/isolation & purification , Hemolytic-Uremic Syndrome/epidemiology , Hemolytic-Uremic Syndrome/microbiology , Adolescent , Adult , Aged , Aged, 80 and over , Biomarkers/blood , Child , Child, Preschool , Creatinine/blood , Disease Outbreaks , Escherichia coli Infections/diagnosis , Female , Hemolytic-Uremic Syndrome/blood , Hemolytic-Uremic Syndrome/diagnosis , Hospitalization/statistics & numerical data , Humans , Infant , Leukocyte Count , Male , Medical Records/statistics & numerical data , Middle Aged , O Antigens , Oklahoma/epidemiology
4.
Emerg Infect Dis ; 12(6): 894-9, 2006 Jun.
Article in English | MEDLINE | ID: mdl-16707043

ABSTRACT

During the 2003-04 influenza season, 17 cases of Staphylococcus aureus community-acquired pneumonia (CAP) were reported from 9 states; 15 (88%) were associated with methicillin-resistant S. aureus (MRSA). The median age of patients was 21 years; 5 (29%) had underlying diseases, and 4 (24%) had risk factors for MRSA. Twelve (71%) had laboratory evidence of influenza virus infection. All but 1 patient, who died on arrival, were hospitalized. Death occurred in 5 (4 with MRSA). S. aureus isolates were available from 13 (76%) patients (11 MRSA). Toxin genes were detected in all isolates; 11 (85%) had only genes for Panton-Valentine leukocidin. All isolates had community-associated pulsed-field gel electrophoresis patterns; all MRSA isolates had the staphylococcal cassette chromosome mec type IVa. In communities with a high prevalence of MRSA, empiric therapy of severe CAP during periods of high influenza activity should include consideration for MRSA.


Subject(s)
Community-Acquired Infections/microbiology , Influenza, Human/microbiology , Orthomyxoviridae , Pneumonia, Bacterial/microbiology , Staphylococcal Infections/microbiology , Staphylococcal Infections/virology , Staphylococcus aureus/isolation & purification , Adolescent , Adult , Child , Child, Preschool , Community-Acquired Infections/virology , DNA, Bacterial/chemistry , DNA, Bacterial/genetics , Electrophoresis, Gel, Pulsed-Field , Female , Genotype , Humans , Infant , Influenza, Human/immunology , Influenza, Human/virology , Male , Methicillin Resistance , Microbial Sensitivity Tests , Middle Aged , Pneumonia, Bacterial/virology , Staphylococcus aureus/drug effects
SELECTION OF CITATIONS
SEARCH DETAIL
...