Continued Gap in Seizure Frequency Documentation

IF 0.2 Q4 PEDIATRICS

Journal of Pediatric Epilepsy Pub Date : 2020-08-31 DOI:10.1055/s-0040-1715461

Andrea Debs, S. Gedela, Anup D. Patel

{"title":"Continued Gap in Seizure Frequency Documentation","authors":"Andrea Debs, S. Gedela, Anup D. Patel","doi":"10.1055/s-0040-1715461","DOIUrl":null,"url":null,"abstract":"Abstract Proper documentation during neurology clinic visits is essential. Medical providers that document precise and standardized findings aid other providers, nurses, and research personnel. The American Academy of Neurology (AAN) created standardized quality measures in order to improve delivery of care for patients with epilepsy, providers, and systems. In this article, we reviewed a total of 777 charts in order to find documentation on seizure frequency from the most recent clinical visit. Data was collected from electronic healthcare records. During initial chart review, the following information was noted: age, gender, seizure type(s), etiology type(s), provider (neurologist or epileptologist), whether seizure frequency was noted, and the reason for no documentation. The data review represented a sample of the epilepsy population seen at our institution. Of the 734 individuals, 475 patients had seizure frequency documented (65%). Two hundred and fifty-nine (259) people (35%) were missing seizure frequency data. For those individuals, we determined the reasoning behind why this data was not present in the chart note. Of those 259 charts, there were 65 (25%) charts missing seizure frequency, 161 (62%) charts that were vague, and 33 (13%) charts where seizure frequency could not be determined. Based on our findings, the documentation of seizure frequency is a gap in care.","PeriodicalId":42559,"journal":{"name":"Journal of Pediatric Epilepsy","volume":null,"pages":null},"PeriodicalIF":0.2000,"publicationDate":"2020-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"2","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Pediatric Epilepsy","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1055/s-0040-1715461","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q4","JCRName":"PEDIATRICS","Score":null,"Total":0}

引用次数: 2

Abstract

Abstract Proper documentation during neurology clinic visits is essential. Medical providers that document precise and standardized findings aid other providers, nurses, and research personnel. The American Academy of Neurology (AAN) created standardized quality measures in order to improve delivery of care for patients with epilepsy, providers, and systems. In this article, we reviewed a total of 777 charts in order to find documentation on seizure frequency from the most recent clinical visit. Data was collected from electronic healthcare records. During initial chart review, the following information was noted: age, gender, seizure type(s), etiology type(s), provider (neurologist or epileptologist), whether seizure frequency was noted, and the reason for no documentation. The data review represented a sample of the epilepsy population seen at our institution. Of the 734 individuals, 475 patients had seizure frequency documented (65%). Two hundred and fifty-nine (259) people (35%) were missing seizure frequency data. For those individuals, we determined the reasoning behind why this data was not present in the chart note. Of those 259 charts, there were 65 (25%) charts missing seizure frequency, 161 (62%) charts that were vague, and 33 (13%) charts where seizure frequency could not be determined. Based on our findings, the documentation of seizure frequency is a gap in care.

查看原文本刊更多论文

扣押频率文件的持续差距

在神经科门诊就诊时，适当的文件是必不可少的。记录精确和标准化结果的医疗提供者可以帮助其他提供者、护士和研究人员。美国神经病学学会(AAN)制定了标准化的质量措施，以改善对癫痫患者、提供者和系统的护理。在这篇文章中，我们回顾了总共777张图表，以便从最近的临床访问中找到癫痫发作频率的文件。数据从电子医疗记录中收集。在最初的病历回顾中，记录了以下信息:年龄、性别、发作类型、病因类型、提供者(神经科医生或癫痫科医生)、是否记录了发作频率以及没有记录的原因。数据回顾代表了在我们机构看到的癫痫人群的样本。在734名患者中，475名患者有癫痫发作频率记录(65%)。259人(35%)缺少癫痫发作频率数据。对于这些人，我们确定了为什么这些数据没有出现在图表说明中的原因。在这259张图表中，有65张(25%)图表缺少癫痫发作频率，161张(62%)图表含糊不清，33张(13%)图表无法确定癫痫发作频率。根据我们的发现，癫痫发作频率的记录是一个空白的护理。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

Journal of Pediatric Epilepsy PEDIATRICS-

自引率

0.00%

发文量

期刊介绍： The Journal of Pediatric Epilepsy is an English multidisciplinary peer-reviewed international journal publishing articles on all topics related to epilepsy and seizure disorders, epilepsy surgery, neurology, neurosurgery, and neuropsychology in childhood. These topics include the basic sciences related to the condition itself, the differential diagnosis, natural history, and epidemiology of seizures, and the investigation and practical management of epilepsy (including drug treatment, neurosurgery and non-medical and behavioral treatments). Use of model organisms and in vitro techniques relevant to epilepsy are also acceptable. Journal of Pediatric Epilepsy provides an in-depth update on new subjects and current comprehensive coverage of the latest techniques used in the diagnosis and treatment of childhood epilepsy.