Abstract The National Emergency Laparotomy Audit (NELA) set out key performance indicators in patients undergoing emergency laparotomy, one of which is the assessment individuals pre-operative risk mortality. This should be made explicit to patient and recorded clearly on consent form medical record.1 Pre-operative mortality can calculated through clinical or using NELA scoring tool. Omission a...

Clinical documentation captured in a patient's record provides health care personnel with information that can be used to guide patient care. Data collected in electronic health records can be accessed and aggregated across the health care delivery system to enhance the safety, quality, and efficacy of care. The updated AORN "Guideline for patient information management" provides guidance to pe...

BACKGROUND A problem encountered by medical examiners is that they have to assess injuries that have already been medically treated. Thus, they have to base their reports on clinical forensic examinations performed hours or days after an injury was sustained, or even base their assessment solely on information gleaned from medical files. In both scenarios, the forensic examiner has to rely heav...

Comparative statistical analyses often require data harmonization, yet the social sciences do not have clear operationalization frameworks that guide and homogenize variable coding decisions across disciplines. When faced with a need to harmonize variables researchers often look for guidance from various international studies that employ output harmonization, such as the Comparative Survey of E...

Registration Online registration available here [5]. Online registration closes Monday, 20 April 2015. Offline registration available here [6]. Education course description available here [7]. View prices here [8]. Exhibitor Information available here. [9] Sponsorship opportunities available here [10]. *Internet sponsorship opportunity available*.

Abstract Background “Documentation burden” in a busy healthcare setting is commonly cited cause for suboptimal documentation and its associated adverse implications. While electronic patient records have been heralded as solution, costs with necessary infrastructure may be prohibitive. We designed implemented standardised surgical admission proforma evaluated impact on improving compliance stan...

Background: Accurate and up-to-date patient records are essential to ensure high standards of clinical care achieve professional from a medico-legal perspective. Objectives: This audit aimed investigate record keeping practices including documentation the evaluation, execution management plan confidentiality organization. Methods: Paper-based 250 outpatients were reviewed randomly using an eval...