The challenges of clinical governance: "informationalising" as socio-technical literacy.

A retrospective cohort study of the 2002 Victorian prehospital emergency care documentation completed by ambulance paramedics had the objectives: (i) to design and implement a quality assessment tool to determine the quality of the ambulance patient care record (PCR) information; and (ii) to identify critical demographic and clinical items on the ambulance PCR that needed improvement. The study outcomes included a functioning quality assessment tool and associated user guide for prehospital use, and the identification of three critical PCR components requiring improvement. Ninety percent of PCRs passed the quality assessment; 10% (approximately 5 300) contained measurably poor or incomplete documentation.