• Title/Summary/Keyword: cancer documentation

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Documentation and Data Collection of Neck Dissection and its Specimen (경부청소술 시료의 기록과 자료의 보관)

  • Choi Eun-Chang;Koh Yoon-Woo;Kim Chul-Ho;Kim Dong-Young
    • Korean Journal of Head & Neck Oncology
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    • v.17 no.1
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    • pp.8-12
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    • 2001
  • It is well established that cervical lymph node metastasis is the base of clinical study on head and neck cancer. But few studies have been reported on lymph node metastasis of head and neck cancer in Korea. We consider it essential that studies on cervical lymph node metastases are conducted on pathologically proven database. Therefore, We must have database and consitent system for documentation and data collection of neck dissection specimen for prospective and retrospective study. Herein, We suggest several points from our experiences performing the proper data collection and documentation of neck dissection specimen.

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Assessment of pain and adequacy of pain management in hospitalized cancer patients

  • Shin, Yeonghee
    • Journal of Korean Academy of Nursing
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    • v.29 no.5
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    • pp.1113-1122
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    • 1999
  • The author investigated pain experiences of 90 cancer patients and the adequacy of pain treatment they have received during their stay at a large medical center in T city between October 1994 and August 1995. Pain was assessed by the Shortened BPQ and results are summarized as follows: As for ratings of “worst pain” during the 24 hour period, 70% of the patients reported they had “severe” pain. As for ratings on “pain now,” 43% of the cancer patients reported “moderate to severe” pain. Over 46% of the patients reported a pain relief score of 0(not at all) or 1(somewhat) even after receiving pain medication. Adequacy of analgesic treatment was evaluated by comparing the patient's reported level of pain and the analgesic use, namely, the pain management index(PMI). The PMI indicated that 58% of the patients were undertreated for the pain control. In review of nurse's notes. systematic pain assessment was scarcely recorded, although pain documentation appeared in 70% of the notes; and the contents were mostly simple description. In conclusion, the results of patient's pain ratings, the PMI and poor pain documentation in the nurse's notes implied poor pain assessment and management.

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Estimation of Completeness of Cancer Registration for Patients Referred to Shiraz Selected Centers through a Two Source Capture Re-capture Method, 2009 Data

  • Sharifian, Roxana;SedaghatNia, Mohammad Hossein;Nematolahi, Mohtram;Zare, Najaf;Barzegari, Saeed
    • Asian Pacific Journal of Cancer Prevention
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    • v.16 no.13
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    • pp.5549-5556
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    • 2015
  • Background: Cancer has important social consequences with cancer registration as the basis of moving towards prevention. The present study aimed to estimate the completeness of registration of the ten most common cancers in patients referred to selected hospitals in Shiraz, Iran by using capture-recapture method. Materials and Methods: This cross-sectional analytical study was performed in 2014 based on the data of 2009, on a total of 4,388 registered cancer patients. After cleaning data from two sources, using capture-recapture common findings were identified. Then, the percentage of the completeness of cancer registration was estimated using Chapman and Chao methods. Finally, the effects of demographic and treatment variables on the completeness of cancer registration were investigated. Results: The results showed that the percentages of completeness of cancer registration in the selected hospitals of Shiraz were 58.6% and 58.4%, and influenced by different variables. The age group between 40-49 years old was the highest represented and for the age group under 20 years old was the lowest for cancer registration. Breast cancer had the highest registration level and after that, thyroid and lung cancers, while colorectal cancer had the lowest registration level. Conclusions: According to the results, the number of cancers registered was very few and it seems that factors like inadequate knowledge of some doctors, imprecise diagnosis about the types of cancer, incorrectly filled out medical documents, and lack of sufficient accuracy in recording data on the computer cause errors and defects in cancer registration. This suggests a necessity to educate and teach doctors and other medical workers about the methods of documenting information related to cancer and also conduct additional measures to improve the cancer registration system.

Comparison of Cancer Nursing. Interventions Recorded in Nursing Notes with Nursing Interventions Perceived by Nurses of an Oncology Unit - Patients with Terminal Cancer - (간호일지 상의 간호중재와 지각된 간호중재의 수행빈도 비교 -말기 암환자를 중심으로-)

  • Chai Ja-Yun;Jang Keum-Seang
    • Journal of Korean Academy of Nursing
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    • v.35 no.3
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    • pp.441-450
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    • 2005
  • Purpose: The purposes of this study were to determine the core nursing interventions in nursing notes and the practice which was perceived by nurses of an oncology unit with patients with terminal cancer. Also, comparing interventions in nursing notes with interventions in perceived practice was done. Method: Subjects were 44 nursing records of patients with terminal cancer who had died from Jan. to Dec. 2002 at C University Hospital and 83 nurses who were working on an oncology unit for more than one year. Data was collected using a Nursing Interventions Classification and analyzed by means of mean and t-test. Results: The most frequent nursing intervention was 'nausea management' in the nursing note and was 'medication administration: oral' in perceived practice. The frequency of nursing interventions in the nursing record was lower than in perceived practice. Conclusion: This study finds that nurses actually practice nursing care, but they may omit records. To correct for omitted nursing records, development of a systematic nursing record system, continuous education and feedback is recommended.

산업보건역학연구사례 - 역학연구논문의 비판(1)

  • Lee, Won-Cheol;Park, Jeong-Il;Maeng, Gwang-Ho
    • 월간산업보건
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    • s.59
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    • pp.24-28
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    • 1993
  • vinyl chloride는 간(liver)의 angiosarcoma를 일으키는 물질로서 이미 잘 알려져 있으며 이들의 관련성은 직업성 암(occupational cancer)의 전형적인 예로 다루어지고 있다. ACGIH에서 발행하는 TLV책자(Documentation of the Threshold Limit Values and Biological Exposure Indices)를 보면 이 물질이 어떠한 역학적인 연구들을 통하여 A1a(Recognized human Carcinogen)에 이르게 되었는지를 알 수 있다. 이 글에서는 vinyl chloride가 남성의 생식기관에 미치는 영향에 대한 논의를 소재로 하여 우리가 역학논물을 대할 때에 어떠한 관점에서 살펴보아야 할 것인가를 논하고자 하였다.

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Information Engineering and Workflow Design in a Clinical Decision Support System for Colorectal Cancer Screening in Iran

  • Maserat, Elham;Farajollah, Seiede Sedigheh Seied;Safdari, Reza;Ghazisaeedi, Marjan;Aghdaei, Hamid Asadzadeh;Zali, Mohammad Reza
    • Asian Pacific Journal of Cancer Prevention
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    • v.16 no.15
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    • pp.6605-6608
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    • 2015
  • Background: Colorectal cancer is a major cause of morbidity and mortality throughout the world. Colorectal cancer screening is an optimal way for reducing of morbidity and mortality and a clinical decision support system (CDSS) plays an important role in predicting success of screening processes. DSS is a computer-based information system that improves the delivery of preventive care services. The aim of this article was to detail engineering of information requirements and work flow design of CDSS for a colorectal cancer screening program. Materials and Methods: In the first stage a screening minimum data set was determined. Developed and developing countries were analyzed for identifying this data set. Then information deficiencies and gaps were determined by check list. The second stage was a qualitative survey with a semi-structured interview as the study tool. A total of 15 users and stakeholders' perspectives about workflow of CDSS were studied. Finally workflow of DSS of control program was designed by standard clinical practice guidelines and perspectives. Results: Screening minimum data set of national colorectal cancer screening program was defined in five sections, including colonoscopy data set, surgery, pathology, genetics and pedigree data set. Deficiencies and information gaps were analyzed. Then we designed a work process standard of screening. Finally workflow of DSS and entry stage were determined. Conclusions: A CDSS facilitates complex decision making for screening and has key roles in designing optimal interactions between colonoscopy, pathology and laboratory departments. Also workflow analysis is useful to identify data reconciliation strategies to address documentation gaps. Following recommendations of CDSS should improve quality of colorectal cancer screening.

Surgical Evaluation of Hemoptysis Patients (객혈환자의 흉부외과적 고찰)

  • Lee, Hyeong-Ryeol;Jeong, Hwang-Gyu
    • Journal of Chest Surgery
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    • v.20 no.1
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    • pp.128-138
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    • 1987
  • The Hippocratic aphorism, "the spitting of pur follows the spitting of blood, consumption follows the spitting of this, and death follows consumption," gives ancient documentation to the significance of hemoptysis in the intrathoracic disease. Hemoptysis is still one of the most alarming and startling of all symptoms. For most patients and not a few doctors, the expectoration of blood signals either pulmonary tuberculosis or cancer. But with the advent of modern thoracic surgical methods, differential diagnosis has become doubly important and appropriate treatment has provided the patients with full recovery or improvement of hemoptysis. Author reviewed 72 cases of patients with a chief complaint of hemoptysis, who were performed open thoracotomies in the Dept. of Thoracic and Cardiovascular Surgery, Pusan National University Hospital for 5 years from April 1980 to March 1985. The results were as follows: 1. The mean age of hemoptysis patients was 35.1 year old with a range from 16 to 64, and hemoptysis was most prevalent in the twenties and male dominant. 2. The most common underlying lung disease of hemoptysis was bronchiectasis [37.5%]. 3. The monthly peak frequency of hemoptysis was in the February [25.[%]. 4. Left lower lobe was the most common site of developing hemoptysis. 5. Lobectomy was the most frequent operative method of all open thoracotomies. 6. The hemoptysis caused by lung cancer recurred most frequently [21.4%], and the prognosis of operation was desperate. 7. The common postoperative complications of hemoptysis patient were re-hemoptysis [24%], bleeding [20%], and atelectasis [16%], and immediate postoperative mortality rate was 2.8%. was 2.8%.

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Use Case Development for Next Generation Electronic Nursing Record Systems Utilizing Clinical Workflow Analysis and a Delphi Survey (차세대 전자간호기록 시스템 유스케이스 개발: 업무흐름 분석과 전문가 델파이 기법 적용)

  • Cho, Insook;Choi, Woan Heui;Hyun, Misuk;Park, Yonok;Lee, Yoona;Lee, Sooyoun;Hwang, Okhee
    • Journal of Korean Clinical Nursing Research
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    • v.21 no.3
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    • pp.377-388
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    • 2015
  • Purpose: To identify user requirements for electronic nursing record (ENR) systems so as to ensure system usability. Methods: A mixed methods approach were applied in three steps : (i) task and workflow analysis with literature review of nursing documentation, (ii) literature reviews of system usability, and (iii) Use Case idenfication and consensus-based validation. We analyzed the nursing activity logs collected from a time-motion investigation of six hospitals. The Use Cases were validated by eight clinical experts from different hospitals and two experts from academia in a sequential Delphi survey. Consensus was achieved for the significance score and agreement among the panel. Results: Eight task groups and patterns of task flow were observed, which were translated into nine Use Cases. The specification of Use Cases was derived from principles, guidelines, and recommendations on nursing documentation and electronic health record systems, which was organized into three requirements of each Use Case: functionality, information, and design characteristics. Each Use Case achieved an agreement of 50~70%, and significance scores of 4 or 5 on a 5-point Likert scale. Conclusion: The nine Use Case identified were considered to be important and adequate in terms of both clinical and informatics contexts.

A Study on the Level of Medical Record Documentation and Agreement in the Information on the Patient's Past History (과거력 의무기록 정보의 기재정도 및 일치도 분석)

  • Seo, Jung-Sook;Yu, Seung-Hum;Oh, Hyohn-Joo;Kim, Yong-Oock
    • Korea Journal of Hospital Management
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    • v.13 no.1
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    • pp.42-64
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    • 2008
  • This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient's past history and through examining the actual medial records. Targeting the information on the patient's past history in interns' records, residents' records and nurses' records toward 403 inpatients who were admitted first in 2004 at an university hospital due to stomach cancer. We analyzed whether the charts were recorded or not, recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement. The results were as follows; first, as for the rate of recording those each items, they were high in the chief complaint & present illness and the past illness history. Depending on the group of recorders, the recording rate showed big difference by items. Second, as a result of measuring the level after dividing the recording level of items for the patient's past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. In the admission department, it was excellent in the interns' records for the medical department. Third, as a result of its satisfactory level by comparing the expect level of a record and the actual record by item in information on the patient's past history, which was expected by the medical-record committee members of the hospital targeted for a study. And forth, we analyzed the level of agreement with Kappa score in the level of 'Yes' or 'None' related to the corresponding matter in Level 1, in terms of information on the past history in the intern's record, the resident's record, and the nurse's record. The level of agreement in the resident's record & the nurse's record, and in the intern's record & the resident's record was from "excellent" to "a little good". There were differences in the level of completeness and in reliability for the information on the past history by the recorder group or by the admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality of care. The items that showed the high recording rate quantitatively were rather low, consequently we'd should develop the tool for the qualitative inspection and evaluate the medical records further. And the items were needed to be detailed in the record level were rather low, and hence there needed to be a documentation guideline and education by the clinical departments.

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The Application of New Calibrator[I-125]Set for Equipment Quality Management (장비정도관리에 Calibrator[I-125] Set 적용)

  • Kim, Ji-Na;An, Jae-seok;Won, Woo-Jae
    • The Korean Journal of Nuclear Medicine Technology
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    • v.19 no.2
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    • pp.108-111
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    • 2015
  • Purpose Lately, in accordance with the increasing interest about Healthcare accreditation program and International laboratory accreditation scheme, requirements about the instrument quality management are gradually taking shape. In nuclear medicine In vitro laboratory, the most typical instruments are multi detector gamma counter and automatic dispensing system. Each laboratory continue with the quality control adequate for circumstances. The purpose of this study is to application and establish the new Calibrator[I-125]Set which is efficient at standardization of equipment quality management. Materials and Methods Deviation between detectors were measured with 12 solid samples of the Calibrator[I-125]Set. their activities differ from each other by less than 1%. Multi detector gamma counters are GAMMA-10;Shinjin medics. Inc, Goyansi, Korea(Gamma counter A), SR300;Stratec biomedical systems AG, Gewerbestr, Germany(Gamma counter B) and COBRA II; Packard Instrument Co. Inc, Meriden, USA(Gamma counter C). Evaluation of two automatic dispensing system used A, B liquid tracer of the Calibrator[I-125]Set. After dispensing and counting, calculated using the ratio of the measured value and proposed value. We used solution A for 20, 25ul and solution B for 50, 100ul. Method of data analysis and reference range was provided by kit documentation. Furthermore, we could calculate our counter efficiency indirectly. Results The CV(%) of measured values by Gamma counter A, B, C are 0.34, 0.70, 1.30. Calculated value are 1.05314, 2.10419, 4.08485. Provided reference range is less than 3. A dispensing system's calculated values are 0.986, 0.989, 1.023, 1.017 and B are 0.874, 0.725, 1.021, 0.904. Provided reference range is from 0.95 to 1.05. Also, counter's efficiency are 74.18, 72.79, 74.32% at counter A, B, C and efficiency of the one detector counter is 79.26%. Conclusion If using this Calibrator[I-125]Set after verifying whether quality assurance, is applicable to equipment quality management on behalf of the role of gold standard.

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