[Recording of anesthesia and recovery phase with a new integrated anesthesia record].
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The International Exposition in Paris in 1937 was of interest to librarians and documentalists for two reasons: an American exhibit of a major microphotographic copying project directed by Herman H. Fussler, and the meeting of the World Congress for Universal Documentation. These two events mark noteworthy stages in the development of library technology and international organization for purposes of bibliographic control.
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Background: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy–paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students' experiences with copy-paste, templates and other "efficiency tools" in EHRs. Purposes: We sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy–paste, templates, auto-inserted data, and "scribing" (documentation under a supervisor's name). Results: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers' notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy–paste policy. Conclusions: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy–paste from other providers, most have observed clinical supervisors doing so.
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Background: Various adjuvants have been used to prolong spinal anesthesia, with the additional advantages of delaying the onset of postoperative pain and reducing postoperative analgesic requirements.Pregabalin is an R-aminobutyric acid analog that binds to the α2-δ subunit of presynaptic voltage-gated calcium channels.Objective: The aim of this work is to evaluate the efficacy of a single dose of pregabalin in terms of spinal blockade duration and its potential opioid-sparing effect during the first 24 hours postoperatively Patients and Methods: There were limitations to the present study.First, since only 1 dosage of pregabalin was evaluated, we could not determine the most effective dosage.Second, clinically meaningful improvements in recovery were not assessed.Adequate postoperative pain control provides early postsurgical mobilization, shortened hospitalization, and increased patient satisfaction.Third, preoperative pain and anxiety scores were not recorded.Pregabalin might affect the preoperative pain, mood, and anxiety scores, and these factors can be related to the postoperative pain score.Results: The mechanisms by which pregabalin premedication prolongs motor and sensory blocks using local anesthetics in spinal anesthesia are not fully understood.There may be several reasons for the prolongation of spinal anesthesia.Gabapentinoids are an raminobutyric acid analog that binds to α2-δ subunit of presynaptic voltage-gated calcium channels, and this inhibition decreases postsynaptic excitability by reducing potassiumevoked excitatory transmitter release.These medications provide antiepileptic, anxiolytic, and analgesic features by modulating both GABAergic neurotransmission and calcium influx.Gabapentinoid compounds produce a significant and clinically important improvement in preoperative anxiety scores.Since patients may be anxious in the perioperative period, the anxiolytic effects and euphorigenic effects of pregabalin may be beneficial.
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Electronic medical records (EMRs) can improve many aspects of patient care(1). Utilization of electronic medical records is increasing and is particularly encouraged by recent federal legislation(2).
However EMRs are not always used optimally. Concerns have been raised about inappropriate copying and pasting of information between provider notes(3, 4). Up to 50% of the content of progress notes may be copied from older documents(5, 6) and copying frequently leads to errors in documentation(6). However, whether copied text generally reflects the care delivered is not known.
Lifestyle counseling improves outcomes in patients with diabetes and is recommended by treatment guidelines(7). Narrative provider notes are the primary source of information on whether lifestyle counseling was provided. However, if copying and pasting of note fragments does not reflect treatment, the information contained in narrative electronic documents may not be reliable.
We therefore performed a retrospective study of over 5,000 patients with diabetes to determine the relationship between copied lifestyle counseling and glucose control.
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The initial findings are presented of a study of 109 patients with hand dysfunction whose hand function was documented with the use of standard office copying equipment. The photocopies obtained by this method provide an inexpensive permanent record of the patient's hand function which can be used to evaluate his treatment and progress and can further be used by those who must establish percentage of disability, compensation, or both.
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