At present, most documentation forms and item catalogs in healthcare are not accessible to the public. This applies to assessment forms of routine patient care as well as case report forms (CRFs) of clinical and epidemiological studies. On behalf of the German chairs for Medical Informatics, Biometry and Epidemiology six recommendations to developers and users of documentation forms in healthca...

STUDY OBJECTIVE This study describes the current documentation practices of health-care providers in the emergency department (ED) during the discharge against medical advice (AMA) process. METHODS This retrospective cohort study reviewed health care provider documentation of adult patients who left an ED AMA in one year. Each encounter documentation was reviewed for eight medicolegal standar...

The "Learning Health System" has been described as an environment that drives research and innovation as a natural outgrowth of patient care. Electronic health records (EHRs) are necessary to enable the Learning Health System; however, a source of frustration is that current systems fail to adequately support research needs. We propose a model for enhancing EHRs to collect structured and standa...

OBJECTIVE To compare documentation of two groups of clinical nutrition practitioners for evidence of the nutrition care process. DESIGN This study used a comparative descriptive design. A retrospective chart review was conducted on all nutrition documentation in closed patient records. Documentation of two groups of nutrition practitioners (institution A=practitioners who received initial ori...

BACKGROUND Female sterilisation is a commonly performed gynaecological procedure that attracts a disproportionate number of complaints and litigation. Documentation of the key counselling issues provides an important record of the information given to the woman prior to undergoing sterilisation. METHODS Auditable standards were obtained from published guidelines. After the initial audit of 10...

OBJECTIVES Ward round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving. METHODS Gold standards were established using the RCSE record keeping guidelines. We audited documentation for seven days using the follow...

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...

OBJECTIVE This study aimed to establish documentation standards for medical education activities, beyond educational research, for academic promotion consistent with principles of excellence and scholarship. METHODS In 2006 a Consensus Conference on Educational Scholarship was convened by the Association of American Medical Colleges (AAMC) Group on Education Affairs (GEA) to outline a set of ...

Abstract Aim Quality of documentation patient notes Method Guidance for standards was taken from ‘The importance Clinical Documentation, Ann R Coll Surg Engl(Suppl) 2014; 96:18–20’ Data 100 patients over 2 weeks. Assessed: Results Availability notes: 15/100 were not available on the wards at time data collection Conclusions Based above results significances of: Unable to provide proof treatment...