We instructed study sites to include all parts of the medical record, including the face sheet, admission note, daily progress notes, procedure notes, medication administration record, diagnostic procedure reports, laboratory test results, physician orders, nursing notes and discharge summary.
Reasons for colonoscopies received in the 10-year period before the reference date were collected from three medical records sources (progress notes; referral notes; procedure reports) and categorized using an algorithm, with committee adjudication of some tests.
Notes: Procedure: Scheffe multiple comparison test; SD = standard deviation;&= statistical trend,*.05 .01; **.01 to.001, inclusive; ***.0005; Statistically significant differences between a NSA and SA,b NSA and RSA, and c SA and RSA groups.
Therefore, careful standardized reviews of information in the progress notes, referral notes and procedure report are necessary for accurate classification of colonoscopy indication.
The patients' medical records, including outpatient and emergency room notes, admission notes, inpatient progress and nursing notes, discharge summaries, procedure notes, surgical reports, radiology reports, pathology reports, and microbiology laboratory results were reviewed.
On a less literary note, the procedure winds up bringing her almost more physical grief than the cancer itself.
Some of their competitors have overly complex processes that require a lot more user involvement than a simple and familiar highlighting and note making procedure.
In the work of Mauch and Dixon[10], an approximate note transcription procedure was applied before calculation of a wrapped chromagram.
> Note: This procedure contains information described in Wiggins and colleagues (2010).
This study compared the information from different clinical data sources for colonoscopy indication classification and found generally good agreement among the progress notes, referral note, and procedure report.
