Introduction Preliminary audit studies in HA (Hospital Authority) hospitals have shown that diagnosis and procedure data reported in the electronic records were very accurate. However, appropriateness is as important as accuracy in clinical documentation. With the introduction of internal resource allocation based on Casemix Pay for Performance (P4P), the relevance of clinical documentation bec...

Introduction. Setting up “Clinical Skills Labs” has been started in some Iranian medical universities since five years ago. In an educational workshop for Clinical Skills Labs managers in January 2001, many managers stated that if there were standards for these centers it would help them define the necessities of the center. These standards would also make the basis for internal and external ev...

Lumbar puncture (LP) is a common invasive procedure in the acute medical setting but is not without its risks and complications, making best clinical practice and correct documentation important for patient safety. Previous audit revealed poor levels of consistency in technique and documentation in the acute medical setting, highlighting it as an area for improvement. This project aims to ident...

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medica...

OBJECTIVES To complete a third round audit of management of shoulder pain using an integrated care pathway, to evaluate pro forma documentation and to determine outcome. SUBJECTS AND SETTING Thirty-four patients with upper limb paresis admitted to a rehabilitation unit during a 22-month period had shoulder pain and were included in the integrated care pathway. METHODS Retrospective review o...

It is a truth universally acknowledged, that software documentation [Lethbridge et al, 2003] is a Good Thing, and spreadsheets are no exception [Morison & Jordan, 2000]. The FSA, in a recent newsletter [FSA, 2006], described what they had seen in the way of good practice for financial modelling systems: “Acceptable standards of documentation were established, agreed by the firm, and themselves ...

Aligning an ICT system with a security standard is a challenging task, because of the sparse support for development and documentation that these standards provide. We create patterns for the elements of trustworthiness: security, risk management, privacy, and law. The instantiations of these patterns are used to support the development and documentation of ICT systems according to security sta...

AIM The aim of the present study was to investigate nurses' opinions about using standardised care plans in electronic health record and quality standards for clinical practice. BACKGROUND Following introduction of an electronic health record, use of standardised care plans and quality standards has increased among nurses at two hospitals in Sweden. Understanding nurses' opinions is important...

In 1998, DiBernardo et al. published a very helpful standardization of comparative (before and after) photographic documentation. These standards prevail to this day. Although most of them are useful for objective documentation of aesthetic results, there are at least 3 reasons why an update is necessary at this time: First, DiBernardo et al. focused on the prevalent standards of medical photog...