H&Ps are not automatically shared with patients through the MyAHS Connect portal, but are easily flagged for sharing by selecting a "Share with patient" button at the top of the note.Īn inpatient encounter that does not have an H&P document type is considered deficient. T he H&P is automatically copied to the patient's family physician, as well as to the provincial electronic health record (Alberta Netcare) and possibly to community electronic medical records (EMRs) serving providers in the patient's circle of care. The H&P also summarizes a patient's health state at a point in time and serves as a key "summative" documentation object in the health record. For patients presenting with more complex problems, the H&P provides an invaluable opportunity to validate core structured data in the patient's chart, including home medications, adverse reactions, active health problems and historical medical, surgical, social and family health problems. The H&P can be as simple as a standardized paragraph containing key information related to, for example, a short-stay surgical encounter. When adding a note to a patient's chart, "H&P" is one of the note types available for selection it is not possible to sign a new note without a type selection. All rights reserved.All inpatient encounters, where a patient is admitted to and later leaves a healthcare facility, must include both admitting and discharge summative documentation.Īn admitting "history and physical" (H&P) document must be filed for all admitted patients. ![]() Quality and consistent ANTT is a safe method for managing intravascular devices, however education and awareness of pathogen transfer from healthcare worker and patient to their device is required.Īseptic non-touch technique Bloodstream infection Bone marrow transplant Catheter related bloodstream infection Central venous access device Needleless connector.Ĭopyright © 2015 Elsevier Ltd. Poor hand hygiene and ANTT were perceived across both groups. No causal effect can be deduced from this small study nevertheless results imply that an ANTT was not associated with increased CRBSI. Infection by skin contaminants were identified in a similar number of cases across both groups (ANTT n = 9 (12.3%) vs Sterile n = 6 (7.8%)). No difference in CRBSI rates between groups was observed (ANTT n = 3 (4%) vs Sterile n = 1 (2.7%), p = 0.357 Fishers Exact Test). One hundred and fifty patients were assessed, 73/150 (49%) in the ANTT group. Laboratory confirmed bloodstream infection, mucosal barrier injury laboratory confirmed bloodstream infection and skin contaminants. A tool was developed to extract historical data from medical records and pathology results. ![]() Haematological malignancy, Hickman catheter inserted, age ≥18. The aim of this study was to determine whether a variation in practice from an aseptic non-touch technique (ANTT) to a sterile technique when changing needleless connectors on central venous access devices (CVAD) was associated with any change in catheter related bloodstream infection (CRBSI) rates in the bone marrow transplant (BMT) population.Ī two group comparative study without concurrent controls using a retrospective cohort was conducted in a large metropolitan hospital in Brisbane, Australia.
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