Medical record documentation quality in the hospital accreditation
نویسندگان
چکیده
منابع مشابه
Quality of nursing documentation before and after the Hospital Accreditation in a university hospital 1
Objective: to analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation, using the Quality of Nursing Diagnoses, Interventions and Outcomes - Brazilian version (Q-DIO- Brazilian version). Method: observational study of interventions conducted in a university hospital. Nursing documentation of 112 medical records for t...
متن کاملMedical Record Documentation Among Interns: A Prospective Quality Improvement Study.
Comprehensive record keeping is a key aspect of medical practice. The National Hospitals Office (NHO) and Irish Medical Council (IMC) have published guidelines in this area. A prospective audit of 100 patients assessed by interns was performed to quantify adherence with these guidelines followed by an educational session and email reminders. Adherence was reassessed in an incidental manner. Com...
متن کاملThe quality of medical record documentation and External cause of fall injury coding in a tertiary teaching hospital.
This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether:...
متن کاملQuality and correlates of medical record documentation in the ambulatory care setting
BACKGROUND Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an...
متن کاملImproving documentation of quality measures in the electronic health record.
PURPOSE Oncology quality measures provide an important tool to evaluate care received by cancer patients. These measures are frequently addressed by oncology nurse practitioners (NPs). NP documentation of quality oncology practice initiative (QOPI) measures in the electronic health record (EHR) is evaluated in this study. DATA SOURCES NP documentation of specific QOPI measures before and afte...
متن کاملذخیره در منابع من
با ذخیره ی این منبع در منابع من، دسترسی به آن را برای استفاده های بعدی آسان تر کنید
ژورنال
عنوان ژورنال: Journal of Education and Health Promotion
سال: 2021
ISSN: 2277-9531
DOI: 10.4103/jehp.jehp_852_20