Browsing by Subject "Documentation"

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  • Sturesson, L.; Lindstrom, V.; Castren, M.; Niemi-Murola, L.; Falk, A. -C. (2016)
    Background: Pain is one of the most common symptoms in the Emergency Department (ED) and is the cause of more than half of the visits to the ED. Several attempts to improve pain management have been done by using, for example, standards/guidelines and education. To our knowledge no one has investigated if and how different actions over a longitudinal period affect the frequency of pain documentation in the ED. Therefore the aim of this study was to describe the frequency of documented pain assessments in the ED. Method: A cross-sectional study during 2006-2012 was conducted. The care of patients with wrist/arm fractures or soft tissue injuries on upper extremities was evaluated. Result: Despite various actions our result shows that mandatory pain assessment in the patient's computerized medical record was the only successful intervention to improve the frequencies of documentation of pain assessment during care in the ED. During the study period, no documentation of reassessment of pain was found despite the fact that all patients received pain medication. Conclusion: To succeed in increasing the frequency of documented pain assessment, mandatory pain rating is a successful action. However, the re-evaluation of documented pain assessment was nonexisting. (C) 2016 Elsevier Ltd. All rights reserved.
  • Winell, Klas; Mikkola, Ilona; Kuronen, Risto; Liira, Helena (2019)
    Hoitosuunnitelma antaa potilaalle mahdollisuuden osallistua hoidon suunnitteluun. Se parantaa pitkäaikais¬sairauksien hoitotuloksia. Hoitosuunnitelmassa luodaan selkeä kuva siitä, mitä hoidoilla yhteisesti tavoitellaan ja miten. Se on oiva väline omahoidon tehostamiseen ja elämäntapamuutosten tukemiseen. Kaikille pitkäaikaissairaille suunnitelma ei ole välttämätön, mutta on tärkeää tunnistaa sitä eniten tarvitsevat. Heille tulee varata riittävästi aikaa hoitosuunnitelmakeskusteluihin.
  • Arminen, Susan; Kinnunen, Marina; Roine, Risto P.; Aaltonen, Leena-Maija (2018)
    Jotta potilaiden hoitoa voidaan kehittää turvallisemmaksi, toiminnan puutteet ja heikkoudet tulee tunnistaa. Miksi-kysymyksillä on porauduttava haittatapahtumien juurisyihin saakka.
  • Rauhala, Auvo; Kinnunen, Marina; Kuosmanen, Anssi; Liukka, Mari; Olin, Karolina; Sahlström, Merja; Roine, Risto P. (2018)
    LÄHTÖKOHDAT Yli 300 sosiaali- ja terveydenhuollon organisaatiota käyttää vapaaehtoista vaaratapahtumien HaiPro-raportointijärjestelmää. Ilmoituksia on tehty yli miljoona. MENETELMÄT Analysoimme tilastollisesti valtaosan ilmoituksista, yhteensä 847 492. TULOKSET Ilmoitusten vuotuinen määrä on kasvussa. Kolmannes koski läheltä piti -tilanteita. Potilaaseen kohdistuneet haitat olivat useimmiten korkeintaan lieviä. Yleisimmin ilmoitukset koskivat lääke- ja nestehoitoa, tapaturmia tai tiedonkulkua. Potilaille oli kerrottu haitoista lähes aina. Lääkärit ilmoittivat vain 2 % tapauksista, ja ilmoituksissa painottuivat vakavat tapahtumat. Kehittämistoimenpiteitä esitettiin harvoin. PÄÄTELMÄT Lääkärien ilmoitusaktiivisuus oli heikko. Syynä lienee huomion painottuminen lääketieteeseen ja mestari-kisällimallin mukaiseen henkilökohtaiseen ohjaukseen enemmän kuin prosesseihin. Tämä ei yleensä johda moniammatilliseen oppimiseen.
  • Lehtonen, Lasse (2018)
    Potilaiden uudet mahdollisuudet tarkastaa lääkärin kirjaamia tietoja johtavat välillä ristiriitoihin. On hyvä muistaa, että potilas¬kertomukseen voi jälkikäteen korjata vain sellaisen tiedon, joka on objektiivisesti arvioiden kirjaushetkellä virheellinen tai tarpeeton.
  • Salonen, Jonna (2016)
  • Heino, A.; Iirola, T.; Raatiniemi, L.; Nurmi, J.; Olkinuora, A.; Laukkanen-Nevala, P.; Virkkunen, I.; Tommila, M. (2019)
    Aim The aim of this study was to evaluate the reliability and accuracy of documentation in FinnHEMS database, which is a nationwide helicopter emergency service (HEMS) clinical quality registry. Methods This is a nationwide study based on written fictional clinical scenarios. Study subjects were HEMS physicians and paramedics, who filled in the clinical quality registry based on the clinical scenarios. The inter-rater -reliability of the collected data was analyzed with percent agreement and free-marginal multi-rater kappa. Results Dispatch coding had a percent agreement of 91% and free-marginal multi-rater kappa value of 0.83. Coding for transportation or mission cancellation resulted in an agreement of 84% and free-marginal kappa value of 0.68. An agreement of 82% and a kappa value of 0.73 for dispatcher coding was found. Mission end, arrival at hospital and HEMS unit dispatch -times had agreements from 80 to 85% and kappa values from 0.61 to 0.73. The emergency call to dispatch centre time had an agreement of 71% and kappa value of 0.56. The documentation of pain had an agreement of 73% on both the first and second measurements. All other vital parameters had less than 70% agreement and 0.40 kappa value in the first measurement. The documentation of secondary vital parameter measurements resulted in agreements from 72 to 91% and kappa values from 0.43 to 0.64. Conclusion Data from HEMS operations can be gathered reliably in a national clinical quality registry. This study revealed some inaccuracies in data registration and data quality, which are important to detect to improve the overall reliability and validity of the HEMS clinical quality register.
  • Heino, A.; Iirola, T.; Raatiniemi, L.; Nurmi, J.; Olkinuora, A.; Laukkanen-Nevala, P.; Virkkunen, I.; Tommila, M. (BioMed Central, 2019)
    Abstract Aim The aim of this study was to evaluate the reliability and accuracy of documentation in FinnHEMS database, which is a nationwide helicopter emergency service (HEMS) clinical quality registry. Methods This is a nationwide study based on written fictional clinical scenarios. Study subjects were HEMS physicians and paramedics, who filled in the clinical quality registry based on the clinical scenarios. The inter-rater -reliability of the collected data was analyzed with percent agreement and free-marginal multi-rater kappa. Results Dispatch coding had a percent agreement of 91% and free-marginal multi-rater kappa value of 0.83. Coding for transportation or mission cancellation resulted in an agreement of 84% and free-marginal kappa value of 0.68. An agreement of 82% and a kappa value of 0.73 for dispatcher coding was found. Mission end, arrival at hospital and HEMS unit dispatch -times had agreements from 80 to 85% and kappa values from 0.61 to 0.73. The emergency call to dispatch centre time had an agreement of 71% and kappa value of 0.56. The documentation of pain had an agreement of 73% on both the first and second measurements. All other vital parameters had less than 70% agreement and 0.40 kappa value in the first measurement. The documentation of secondary vital parameter measurements resulted in agreements from 72 to 91% and kappa values from 0.43 to 0.64. Conclusion Data from HEMS operations can be gathered reliably in a national clinical quality registry. This study revealed some inaccuracies in data registration and data quality, which are important to detect to improve the overall reliability and validity of the HEMS clinical quality register.