Neurosurgical Documentation [Neurosurgery Wiki]

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== Neurosurgical Documentation ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1zwxnl3goFY0U2_ZRcle0Njv7Cwg_rPX_Sj42NeUYo61Cw1gMo/?limit=15&utm_campaign=pubmed-2&fc=20230620135404}}
----
----
Clinical [[documentation]] has been a cornerstone of medical [[care]] for hundreds of years, if not longer
((Gillum RF. From papyrus to the electronic
tablet: A brief history of the clinical medical
record with lessons for the digital age. Am J
Med. 2013;126:853–857.)).

see [[Medical history]].

===== Administrative database =====
[[Administrative database]]

===== Purposes =====

The products of such documentation, serve many purposes: reminding the note author of what they did, communicating to other [[provider]]s both in the present and the future, justifying a level of service provided and a fee charged, defending decisions in case of [[malpractice]] accusations,
providing data for research and quality improvement, and even communicating with patients as in [[OpenNotes]]
((Delbanco T, Walker J, Darer JD, et al. Open
notes: Doctors and patients signing on. Ann
Intern Med. 2010;153:121–125.))
((Wolff JL, Darer JD, Berger A, et al. Inviting
patients and care partners to read doctors’
notes: OpenNotes and shared access to
electronic medical records. J Am Med Inform
Assoc. 2017;24(e1):e166–e172.))
((Bell SK, Mejilla R, Anselmo M, et al. When
doctors share visit notes with patients: A
study of patient and doctor perceptions of
documentation errors, safety opportunities
and the patient–doctor relationship. BMJ
Qual Saf. 2017;26:262–270.)).

The last major paradigm shift in documentation occurred in 1968 when Dr. Larry Weed proposed the problem-oriented medical record
((Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar
14;278(11):593-600. PubMed PMID: 5637758.
)).

Weed presaged and welcomed [[electronic health record]]s (EHRs)
((Slack WV, Hicks GP, Reed CE, Van Cura LJ.
A computer-based medical-history system. N
Engl J Med. 1966;274:194–198)), 
writing that “it can readily be seen that … in the future all narrative data may be entered through [a] series of displays.

Clinical documentation is usually stored in an unstructured format in [[electronic health record]]s (EHR). Processing the information is inconvenient and time-consuming and should be enhanced by computer systems. In this paper, a rule-based method is introduced that identifies adverse events documented in the EHR that occurred during treatment. For this purpose, clinical documents are transformed into a semantic structure from which adverse events are extracted. The method is evaluated in a user study with neurosurgeons. In comparison to a bag of word classification using support vector machines, our approach achieved comparably good results of 65% recall and 78% precision. In conclusion, the rule-based method generates promising results that can support physicians' decision making. Because of the structured format the data can be reused for other purposes as well
((Gaebel J, Kolter T, Arlt F, Denecke K. Extraction Of Adverse Events From
Clinical Documents To Support Decision Making Using Semantic Preprocessing. Stud 
Health Technol Inform. 2015;216:1030. PubMed PMID: 26262330.
)).
----
Neurosurgical [[documentation]] refers to the process of [[record]]ing and documenting [[information]] related to [[neurosurgical procedure]]s and [[patient care]]. It involves creating accurate and [[comprehensive]] [[medical record]]s that capture the details of the [[surgical intervention]], [[patient assessment]], [[operative findings]], [[neurosurgical techniques]], [[postoperative care]], and [[follow-up]].

Effective neurosurgical documentation helps ensure continuity of care, facilitates communication among [[healthcare provider]]s, supports [[research]] and [[quality]] improvement initiatives, and serves as a [[legal]] record of the patient's [[treatment]]. It should be timely, legible, [[objective]], and comply with relevant [[documentation]] [[guideline]]s, such as those set forth by regulatory bodies and professional organizations.


===== Preoperative Neurosurgical Documentation =====

[[Preoperative Neurosurgical Documentation]].

===== Intraoperative Documentation =====

[[Intraoperative Documentation]].

===== Operative Notes =====

[[Operative Notes]]

===== Postoperative Documentation =====

[[Postoperative Documentation]] 

[[Progress Notes]] and [[Follow-up]]

[[Coding]] and [[Billing Documentation]]



===== Prospective quality registries =====
[[Prospective quality registries]].

===== Case reports =====

see [[Case report]].


===== Storing =====

there are several options available depending on the type and amount of data you need to store. Here are some common methods of storing information:

Hard drives: Hard disk drives (HDD) and solid-state drives (SSD) are commonly used for storing data on personal computers and servers. They offer varying capacities and are suitable for storing large amounts of data.

Cloud storage: Cloud storage services allow you to store data on remote servers accessed through the internet. Popular cloud storage providers include Google Drive, Dropbox, and Microsoft OneDrive. Cloud storage offers convenience, scalability, and accessibility from multiple devices.

Network-attached storage (NAS): NAS devices are dedicated file storage devices connected to a network. They provide centralized storage for multiple devices and can be accessed by authorized users over a local network or remotely.

External storage devices: External hard drives, USB flash drives, and SD cards provide portable storage options for backing up or transferring data. These devices are widely available and offer different capacities to suit your needs.

Optical storage: CDs, DVDs, and Blu-ray discs are optical storage media that can store data, music, videos, or software. However, their storage capacity is relatively limited compared to other options.

Tape storage: Magnetic tape storage is primarily used for long-term archival and backup purposes. It offers high storage capacities and is often used in enterprise-level data storage systems.

When choosing a storage method, consider factors such as data security, accessibility, scalability, cost, and backup options. It's often advisable to have multiple copies of important data stored in different locations or using redundant storage systems to minimize the risk of data loss.