BACKGROUND: Inconsistent reporting of patient characteristics in clinical research hampers reproducibility and limits analysis opportunities. This paper proposes condition-specific \'Core Descriptor Sets\' comprising key factors like demographics, disease severity, comorbidities, and prognosis to standardize Table 1 reporting.
METHODS: Development entails stakeholder involvement, systematic identification of descriptors, value rating, and consensus-building using multiple Delphi rounds. Final agreement comes at an expert meeting.
CONCLUSIONS: Benefits include easier cross-study comparison, for example, through individual patient meta-analysis, facilitated by comparison of consistently reported individual data rather than group-level analysis. This may also support routine data analyses, subgroup and risk identification, and reduced research waste. Core Descriptor Sets describe cohorts thoroughly while minimizing research burden. They are intended to enable improved clinical characterization, personalization, reproducibility, data sharing, and knowledge building.

Purpose: Improvements in outcomes for adolescent and young adult (AYA) oncology patients have lagged behind those of other age-specific cancer populations. Research has indicated that low availability of clinical trials, biological differences of this age-group, and several psychosocial factors including higher emotional distress impact outcomes. To improve care and survival rates for these patients, hospitals have implemented AYA oncology programs. The current study evaluated documentation of care in an AYA program housed in an academic medical center based on three areas emphasized in the National Comprehensive Cancer Network\'s Clinical Practice Guidelines in Oncology for AYAs: clinical trial enrollment, fertility, and psychosocial care. Methods: Retrospective chart reviews were conducted for 45 patients treated before the start of the AYA oncology program and 45 patients treated after program initiation. Patients aged 15-39 years with a diagnosis of a malignant tumor were included. Variables evaluated included documentation of clinical trial enrollment, fertility preservation and sexual health considerations, and behavioral health referrals. Results: Documentation of most clinical trial and fertility variables did not significantly improve from pre- to post-program, although a higher number of patients had these variables documented post-program. Behavioral health referrals increased significantly from 52.8% pre-program to 95.4% post-program. Conclusion: Access to behavioral health care improved the most following implementation of our AYA program, which is likely because of the integration of a dedicated psychologist for AYAs when the program began. The practice of guideline-based care for this population can be better assessed and improved with designated behavioral health providers and more systematic documentation processes.

UNASSIGNED: In the current body of forensic literature, there is little guidance available regarding death investigations of transgender, intersex, and gender diverse individuals. An increase in the prevalence of gender diverse identifying people and the frequency in which these individuals experience a premature death makes it more likely these deaths will fall under the jurisdiction of the medical examiner\'s office. The inability to navigate these diverse cases due to a lack of training, education, and support may leave forensic professionals without the tools needed to accurately represent these deaths.This narrative review is intended to provide the foundational knowledge needed by forensic death investigators when investigating gender identity in death, including suggested guidelines for a more effective and empathetic death investigation. A better understanding of the implications and applications of this information when included in reports will bolster the quality and quantity of the data reported and collected. This will lead to more accurate monitoring and reporting of violent, suicidal, and homicidal deaths of transgender, intersex, and other gender diverse individuals, and a higher identification rate of unidentified remains with gender diverse markers.

OBJECTIVE: To investigate whether implementation of a hospital-based Extended Focused Assessment with Sonography in Trauma (eFAST) guideline and teaching improved documentation and saving of images.
METHODS: A retrospective cohort study was conducted on trauma patients aged ≥16 years presenting to St Vincent\'s Hospital Sydney Emergency Department over two, three-month periods in 2023.
RESULTS: Guideline and teaching implementation resulted in statistically significant improvement in documentation on the Trauma Response Form, 85% (113/133) to 93% (120/129), odds ratio (OR) 2.4 (95% confidence interval [CI] = 1.03-5.40), P = 0.04, and images saved, 4% (5/133) to 21% (27/129), OR 6.7 (95% CI = 2.5-18.2), P < 0.001.
CONCLUSIONS: Developing an eFAST Standard of Care Guideline and education was associated with improvements in documentation and saving of images to ultrasound machines.

BACKGROUND: Medication review practices have evolved internationally in a direction in which not only physicians but also other healthcare professionals conduct medication reviews according to agreed practices. Collaborative practices have increasingly highlighted the need for electronic joint platforms where information on medication regimens and their implementation can be documented, kept updated, and shared.
OBJECTIVE: The aim of this study was to harmonize the definition of medication reviews and create a unified conceptual basis for their collaborative implementation and documentation in electronic patient records (definition appellation: collaborative medication review).
METHODS: The study was conducted using the Delphi consensus survey with three interprofessional expert panel rounds in September-December 2020. The consensus rate was set at 80%. Experts assessed the proposed definition of collaborative medication review based on an international and national inventory of medication review definitions. The expert panel (n = 41) involved 12 physicians, 13 pharmacists, 10 nurses, and six information management professionals. The range of response rates for the rounds was 63-88%.
RESULTS: The experts commented on which of the pre-selected items (n = 75) characterizing medication reviews should be included in the definition of collaborative medication review. The items were divided into the following five themes and 51 of them reached consensus: 1) Actions included in the collaborative medication review (n = 24/24), 2) Settings where the review should be conducted (n = 5/5), 3) Situations where the review should be considered as needed and carried out (n = 10/11), 4) Prioritization of top five benefits to be achieved by the review and 5) Prioritization of top five patient groups to whom the review should be targeted.
CONCLUSIONS: A strong interprofessional consensus was reached on the definition of collaborative medication review. The most challenging was to identify individual patient groups benefiting from the review.

OBJECTIVE: To assess the performance of our urology team against General Medical Council (GMC) guidelines for using chaperones during intimate clinical examination.
BACKGROUND: Intimate physical examination is an integral part of our urological practice. There is a paucity of literature regarding the use of chaperones among urologists. Given the importance of this topic for both patient safety and providing support for the urologist, we decided to assess our performance as per the GMC guidelines for good medical practice.
METHODS: We completed an audit loop to evaluate the performance of 12 members in our urology team as regards compliance with GMC guidance for the documentation of chaperone use in the urology clinic. Based on our scoring system, we objectively assessed both overall team performance and individual scores for documenting chaperone use.
RESULTS: There was a significant improvement in the overall documentation rate in both clinical notes (+9.85%) and clinic letters (+36.65%). Raising awareness among team members managed to increase the individual performance scores as well.
CONCLUSIONS: This is the first report using a scoring system for objective assessment of a pertinent topic such as the use of chaperone and its documentation. This managed to achieve a significant improvement in our practice.

Background Thorough and precise operative notes play a vital role in patient care, facilitating communication among healthcare teams and serving as essential documents for legal purposes. Poor documentation can jeopardize patient safety and the quality of care provided. The use of standardized guidelines, such as those endorsed by recognized surgical organizations, is crucial to ensure consistent and detailed record-keeping. This study aims to assess the alignment of postoperative notes with established guidelines, with the goal of enhancing documentation practices in the healthcare setting. Objectives This study aimed to evaluate the quality and comprehensiveness of postoperative surgical notes and assess their alignment with established guidelines for surgical documentation, specifically focusing on adherence to recognized standards in surgical practice. Methods This cross-sectional audit assessed 150 operative notes (79 pre-implementation and 71 post-implementation of the Royal College of Surgeons (RCS) guidelines) in the General Surgery Unit at Khyber Teaching Hospital Peshawar, Pakistan. Data included peri-operative findings, operative diagnosis, team information, operational details, complications, procedures, prosthesis, closure, DVT prophylaxis, time out, postoperative orders, and signatures. Results Post-implementation, peri-operative findings were noted in 68 (95.7%) notes, compared to 56 (70.8%) pre-implementation. Operative diagnosis consistently increased from 65 (82.3%) to 69 (97.2%). Post-implementation, operation type, date, and time were consistently included in 67 (94.4%) notes. Complications, additional procedures, and tissue alterations surged to 66 (92.9%), 64 (90.1%), and 60 (84.5%), respectively. Prosthesis and closure techniques were recorded in 65 (91.5%) and 66 (92.9%). Deep vein thrombosis (DVT) prophylaxis and \"time out\" were documented in 68 (95.8%) notes. Postoperative orders and signatures improved to 70 (98.6%) and 69 (97.2%), respectively. Conclusion Our study revealed the significant positive impact of RCS guideline implementation on operative note documentation. Improvements were noted in essential components such as peri-operative findings, diagnosis, team details, complications, procedures, and more. These enhancements have far-reaching implications, bolstering patient care and ensuring clear communication among healthcare providers, all while serving a vital role in medico-legal matters. By adopting the RCS guidelines, healthcare institutions commit to a higher documentation standard, ultimately supporting good clinical governance.

To determine if accurate documentation of bladder cancer risk was associated with a clinician surveillance recommendation that is concordant with AUA guidelines among patients with nonmuscle invasive bladder cancer (NMIBC).
We prospectively collected data from cystoscopy encounter notes from four Department of Veterans Affairs (VA) sites to ascertain whether they included accurate documentation of bladder cancer risk and a recommendation for a guideline-concordant surveillance interval. Accurate documentation was a clinician-recorded risk classification matching a gold standard assigned by the research team. Clinician recommendations were guideline-concordant if the clinician recorded a surveillance interval that was in line with the AUA guideline.
Among 296 encounters, 75 were for low-, 98 for intermediate-, and 123 for high-risk NMIBC. 52% of encounters had accurate documentation of NMIBC risk. Accurate documentation of risk was less common among encounters for low-risk bladder cancer (36% vs 52% for intermediate- and 62% for high-risk, P < .05). Guideline-concordant surveillance recommendations were also less common in patients with low-risk bladder cancer (67% vs 89% for intermediate- and 94% for high-risk, P < .05). Accurate documentation was associated with a 29% and 15% increase in guideline-concordant surveillance recommendations for low- and intermediate-risk disease, respectively (P < .05).
Accurate risk documentation was associated with more guideline-concordant surveillance recommendations among low- and intermediate-risk patients. Implementation strategies facilitating assessment and documentation of risk may be useful to reduce overuse of surveillance in this group and to prevent unnecessary cost, anxiety, and procedural harms.

The length and redundancy of notes authored by clinicians has significantly increased, giving rise to the term \"note bloat.\" We analyzed the impact of new coding guidelines and documentation best practices on the length of emergency department (ED) notes and the amount of time clinicians spent documenting.
In a large, multisite health care delivery organization, we retrospectively evaluated the length of all ED provider notes and the amount of time clinicians spent documenting between February 2018 and June 2023. In January 2023, we implemented changes to the standardized note template to align with the new coding guidelines from the American Medical Association and the Centers for Medicare & Medicaid Services. The primary outcomes were the length of provider notes and the amount of time spent documenting.
Our study sample consisted of 1,679,762 ED provider notes. Six months after the intervention, the average note length decreased by 872 words (95% confidence interval 867 to 877 words), whereas the amount of time clinicians spent documenting did not change.
Embracing new guidelines and practices, we reduced the length of ED provider notes by 872 words. Despite this, the time clinicians spent documenting did not change significantly. We provide an early report of success in reducing note bloat in the ED to help guide future efforts to reduce overall documentation burden.

BACKGROUND: The 4th update of the guidelines of the German Medical Association on the diagnosis of irreversible loss of brain function (brain death, BD) has introduced important new regulations regarding the required qualification of the examiners, approved procedures for ancillary testing, and a clarification regarding the sequencing of diagnostic steps.
OBJECTIVE: Investigation of the implementation and practical effects on the diagnosis of brain death.
METHODS: Descriptive evaluation of the routine documentation of the German Organ Procurement Organization, comparing the periods July 2011-June 2015 (3rd update) and July 2015-June 2019 (4th update).
RESULTS: Patient numbers decreased from 6100 to 5403. The largest decrease affected hospitals without neurosurgery. Children were not affected. With the 4th update, clinical diagnostics were increasingly performed during on-call hours by external neurologists. Of the patients 83.8% now received ancillary tests compared to 80.1% previously. Computed tomography angiography (CTA), first introduced in the 4th update, was applied in 23.2% and established complete loss of cerebral circulation in 89.4%. The time between first documentation of the clinical signs of BD and certification of BD increased from 7.0 ± 12.7 h to 8.2 ± 14.2 h. The diagnosis was slightly less frequent with 95.3% compared to 96.6%.
CONCLUSIONS: The updated standards were implemented in accordance with the guidelines. The demand for external consulting neurologists and neurosurgeons as well as the time required for BD assessment have increased. Negative effects on pediatric BD diagnostics were not apparent. CTA is widely and successfully used in adults as a new ancillary diagnostic procedure.
UNASSIGNED: HINTERGRUND: Seit Inkrafttreten der 4. Fortschreibung der Richtlinie der Bundesärztekammer gelten in Deutschland wesentliche neue Normierungen in der Diagnostik des irreversiblen Hirnfunktionsausfalls (IHA). Hierzu zählen die Qualifikationsanforderungen an die Untersucher, zugelassene Verfahren zur apparativen Zusatzdiagnostik und eine Präzisierung zur Abfolge der Prozessschritte.
UNASSIGNED: Untersuchung der Auswirkungen auf die Praxis der IHA-Feststellung.
METHODS: Deskriptive Auswertung der Dokumentation der Deutschen Stiftung Organtransplantation über IHA-Diagnostik im Vergleich der Zeiträume Juli 2011 bis Juni 2015 (3. Fortschreibung) und Juli 2015 bis Juni 2019 (4. Fortschreibung).
UNASSIGNED: Die Zahl der erfassten Patienten sank von 6100 auf 5403. Die stärkste Abnahme betraf Krankenhäuser ohne Neurochirurgie. Kinder unter 14 Jahren waren nicht betroffen. Die klinische Diagnostik erfolgte ab Juli 2015 vermehrt im Bereitschaftsdienst durch externe neurologische Konsiliare. Zusatzdiagnostik erhielten nun 83,8 % der Patienten, zuvor 80,1 %. Die neu etablierte CTA wurde bei 23,2 % eingesetzt. Sie wies in 89,4 % den zerebralen Zirkulationsstillstand nach. Die Zeitdauer zwischen erstmaliger Feststellung der klinischen Ausfallzeichen und Feststellung des IHA stieg von 7,0 ± 12,7 h auf 8,2 ± 14,2 h. Der IHA wurde mit 95,3 % gegenüber 96,6 % geringfügig seltener festgestellt.
CONCLUSIONS: Die neuen Normierungen wurden richtlinienkonform umgesetzt. Der Bedarf an konsiliarischer Unterstützung durch Neurologen und Neurochirurgen sowie der Zeitbedarf für die IHA-Feststellung haben zugenommen. Negative Effekte auf die pädiatrische IHA-Diagnostik wurden nicht deutlich. Die CTA wird bei Erwachsenen als neues zusatzdiagnostisches Verfahren flächendeckend erfolgreich eingesetzt.