Documentation is a professional responsibility and is a form of communication to stakeholders, demanding health professionals including occupational therapists, to provide accountable records encompassing the occupational therapy process which includes evaluation, intervention, and outcomes. However, there are no clear guidelines for occupational therapy documentation. There is a lack of uniformity of content in documentation among therapists and facilities, and the length required to create the report are pertinent problems encountered. The purpose of this article is to report on the conceptual model to guide occupational therapists in creating efficient and occupation-centered evaluation documentation. With this, the proposed Dollhouse Model aims to answer the question: “What do you prioritize when creating pediatric evaluation documentation?” Utilizing this model suggests that therapists may be able to prioritize the pertinent occupational areas to document, therefore making it more efficient and occupation-centered.
documentation ; assessment ; occupational therapists ; occupational therapy ; health professionals

INTRODUCTION: Timely administration of prophylactic antibiotics within 60 minutes before surgical incision is important for reducing surgical site infections. This quality improvement initiative aimed to work towards achieving 100% compliance with perioperative antibiotic administration. METHODS: We examined the workflow in our Anaesthesia Information Management System (AIMS) and proposed interventions using cause-and-effect analysis of anonymised anaesthetic records from eligible surgical cases extracted from AIMS. This ultimately led to the implementation of an antibiotic pop-up reminder. The overall process was done in a few small plan-do-study-act cycles involving raising awareness, education and reorganisation of AIMS before implementation of the antibiotic pop-up reminder. Data analysis took place from August 2014 to September 2016. Compliance was defined as documented antibiotic administration within 60 minutes before surgical incision, or as documented reason for omission. RESULTS: The median monthly compliance rate, for 33,038 cases before and 28,315 cases after the reminder was implemented, increased from 67.0% at baseline to 94.5%. This increase was consistent and sustained for a year despite frequent personnel turnover. Documentation of antibiotic administration also improved from 81.7% to 99.3%, allowing us to identify and address novel problems that were initially not apparent, and resulting in several department recommendations. These included administering antibiotics later for cases with predicted longer-than-expected preparation times and bringing forward antibiotic administration in lower-segment Caesarean sections. CONCLUSION The use of information technology and implementation of an antibiotic pop-up reminder on AIMS streamlined our work processes and brought us closer to achieving 100% on-time compliance with perioperative antibiotic administration.
Anti-Bacterial Agents ; administration & dosage ; Antibiotic Prophylaxis ; methods ; Documentation ; Drug Administration Schedule ; Electronic Health Records ; Guideline Adherence ; Humans ; Perioperative Period ; Quality Improvement ; Reminder Systems ; Software ; Surgical Procedures, Operative ; standards ; Surgical Wound Infection ; prevention & control

PURPOSE: This study was done to develop a evidence-based guideline for pain assessment and management in Korea by adapting previously developed pain guidelines. METHODS: The guideline adaptation process was conducted using 24 steps according to the guideline adaptation manual developed by Hospital Nurses Association in 2012. RESULTS: The newly developed pain management guideline consisted of 9 domains and 234 recommendations. The number of recommendations in each domain was: 13 general instruction items, 51 pain assessments, 14 pain interventions, 66 pharmacological interventions for acute pain, 41 pharmacological interventions for chronic cancer pain, 35 pharmacological interventions for chronic noncancer pain, 21 non-pharmacological interventions, 2 documentations, 10 nursing education items, for pain. CONCLUSION: The findings suggest that the new pain management guideline can be used to address pain in hospital settings.
Acute Pain ; Documentation ; Education, Nursing ; Evidence-Based Nursing ; Korea ; Nursing ; Pain Management ; Pain Measurement

Medical reports are required to support court applications to appoint a deputy to make decisions on behalf of a person who has lost mental capacity. The doctor writing such a medical report needs to be able to systematically assess the mental capacity of the person in question, in order to gather the necessary evidence for the court to make a decision. If the medical report is not adequate, the application will be rejected and the appointment of the deputy delayed. This article sets out best practices for performing the assessment and writing the medical report, common errors, and issues of concern.
Documentation ; Humans ; Mental Competency ; legislation & jurisprudence ; Patient Advocacy ; legislation & jurisprudence ; Physicians ; legislation & jurisprudence ; Proxy ; legislation & jurisprudence ; Singapore ; Third-Party Consent ; legislation & jurisprudence ; Vulnerable Populations ; legislation & jurisprudence ; Writing

The management for qualification documents of medical instruments is very important work to management department of medical instruments. Because the number of qualification documents of medical instruments is very large and they have an expiry date, it is difficult to manage them. This article discussed how to manage qualification documents of medical instruments, and an information management system that has a function of traceability management has been developed. This information management system standardizes management for qualification documents of medical instruments, and ensures that qualification documents of medical instruments are available and can be traced. Besides, it can reduce the amount of work for medical instruments management.
Documentation ; standards ; Equipment and Supplies ; standards ; Information Systems

Abdomen ; diagnostic imaging ; Attitude of Health Personnel ; Checklist ; Documentation ; methods ; Humans ; Liver ; diagnostic imaging ; Physicians ; Radiologists ; Radiology ; Referral and Consultation ; Surveys and Questionnaires ; Tomography, X-Ray Computed ; Ultrasonography

Tumor specimens have a great role in basic and clinical translational researches on cancer, especially in the era of precision medicine. Thus the standardization of cancer biobank is of high importance. The establishment and maintenance of cancer biobank require comprehensive quality management, so as to provide high quality service for basic and clinical researches. At present, sample-oriented collection and management, and clinical and pathological data annotation are the main focuses of biobank standardization in China.
Biological Specimen Banks ; standards ; Biomedical Research ; China ; Documentation ; standards ; Humans ; Neoplasms ; Precision Medicine ; Specimen Handling ; standards

A CDASH-based CRF annotation plays an important role in database setup and data verification. The STDM-based CRF annotation is also one of the essential documents when the package of clinical trial data is submitted to the regulatory authority. This paper describes the contents, procedures and related stipulations used in the CDISC-based CRF annotation.
Clinical Trials as Topic ; Databases, Factual ; Documentation ; standards

Case report form (CRF) is a key document for data collection in clinical trials. A well-designed CRF is required for database construction, data accuracy, data query/cleaning, CRF completion and statistical analysis. A well-defined process or SOP should be in place for CRF design. Data collection should fully meet the demand of study protocol. The layout of CRF should be clear with well-structured fields and standard coding for fields.
Clinical Trials as Topic ; standards ; Data Collection ; standards ; Documentation ; standards ; Research Design ; standards

Source data and its source documents are the foundation of clinical research. Proper source data management plays an essential role for compliance with regulatory and GCP requirements. Both paper and electronic source data co-exist in China. Due to the increasing use of electronic technology in pharmaceutical and health care industry, electronic data source becomes an upcoming trend with clear advantages. To face new opportunities and to ensure data integrity, quality and traceability from source data to regulatory submission, this document demonstrates important concepts, principles and best practices during managing source data. It includes but not limited to: (1) important concepts of source data (e.g., source data originator, source data elements, source data identifier for audit trail, etc.); (2) various modalities of source data collection in paper and electronic methods (e.g., paper CRF, EDC, Patient Report Outcomes/eCOA, etc.); (3) seven main principles recommended in the aspect of data collection, traceability, quality standards, access control, quality control, certified copy and security during source data management; (4) a life cycle from source data creation to obsolete is used as an example to illustrate consideration and implementation of source data management.
China ; Data Collection ; standards ; Documentation ; standards ; Information Storage and Retrieval ; methods ; standards