Transition to a computer-based record using scannable, structured encounter forms.

OBJECTIVE: To evaluate the quality of documentation and user satisfaction with a structured documentation system for pediatric health maintenance encounters, using scanned paper-based forms to generate an electronic medical record. DESIGN: (1) A retrospective medical record review comparing 16 structured (ST) records with 16 contemporaneously created unstructured records, (2) a questionnaire evaluation of user satisfaction, and (3) an electronic records review of patients seen 1 year following the full implementation of the system to evaluate persistence of the effect. SETTING: The Yale-New Haven Hospital Pediatric Primary Care Center, New Haven, Conn, an inner-city clinic in an academic center. PARTICIPANTS: (1) A random sample of 16 health maintenance records completed by first- and second-year residents in February 1996 matched for patient's age and provider training level with 16 contemporaneously documented visits, (2) 16 of 18 pediatric level 1 residents and 14 of 16 pediatric level 2 residents who completed questionnaires, and (3) all electronic records of health maintenance visits during February 1997. MAIN OUTCOME MEASURES: The number of data elements documented and the percentage of records that record specific components of the health maintenance encounter. User satisfaction was specified on a Likert scale. RESULTS: Overall, residents in the ST records group documented more data elements per visit than did those in the unstructured records group. The number of developmental items documented was 11.5 per visit in the ST records group and 4.8 per visit in the unstructured records group (P = .004). Likewise, anticipatory guidance was more thoroughly documented in the ST records group--8.3 items per visit vs 2.5 items per visit (P < .001). Ninety percent of the users preferred the ST records. One year after the adoption of the ST recording system, high levels of thoroughness persisted. CONCLUSIONS: Structured, scannable encounter forms can facilitate documentation of patient care and are well accepted by users. They can provide an effective mechanism to ease the transition to a computer-based patient record.

Arterialized venous flaps for reconstructing soft-tissue defects of the extremities.

Four cases of soft-tissue defects of the extremities are presented. Each defect was covered by a fasciocutaneous venous free flap in which arterial inflow relied solely on the venous pedicle. India ink injection of the saphenous vein in eight cadaver lower extremities revealed that only the subdermal venous plexus supplies the cutaneous island. Clinically, flaps ranged in size from 4 x 6 cm to 5 x 9 cm. Three flaps survived completely, while one flap lost the cutaneous portion of its skin island. However, the subcutaneous tissue survived. Although free venous fasciocutaneous flaps have a more tenuous blood supply in the immediate postoperative period, this flap can be transferred successfully without the sacrifice of a donor artery.

Soft-tissue repair of myelomeningocele defects using bilateral latissimus dorsi and trapezius musculocutaneous flaps.

An urgent closure of myelomeningocele defects was carried out in 82 newborns using latissimus and/or trapezius musculocutaneous advancement flaps. A three-layer closure of skin, muscle, and fascia was achieved in a single stage without a flank skin graft. All of the wounds healed within a two-week period and no late breakdown of the wound occurred during the eight-year period of study. The urgent closure maximized the neurological salvage and facilitated early cerebrospinal fluid shunting by preventing both infection and neural desiccation. This report represents the largest number of sequentially treated myelomeningocele defects without a major wound healing problem or death. The advancement musculocutaneous flap closure is safe, simple, and effective and is recommended as the preferred method for closure of the myelomeningocele defect.

The quantitative study of the use of dextranomer in the management of infected wounds.

Open wounds using quantitative cultures and dextranomer were analyzed. Dextranomer has been shown to be an extremely effective local wound care agent, provided that the wound has an adequate blood supply and complete removal of the used dextranomer is achieved. Under these circumstances, dextranomer provides a rapid and effective means for the treatment of open, exudative wounds.