نتایج جستجو برای: clinical documentation standards
تعداد نتایج: 1292435 فیلتر نتایج به سال:
The Clinical Data Interchange Standards Consortium (CDISC) has succeeded in developing global clinical data interchange standards that are ready for implementation. The various CDISC models are identified and explained in this article as well as how these models work together. In addition to developing the CDISC standards, CDISC is involved actively in many collaborative projects with other org...
Abstract Aim To assess the effect of COVID 19 on ward notes documentation standards Method 100 entries (before COVID, during Peak, and after each) were evaluated against set derived from GMC Good Medical Practice document. The results analysed, three data sets compared to any pandemic standards. Results Individually, clear handwriting documenting signatures showed a slight decline, increase was...
Data standards consisting of key data elements for clinical routine and trial documentation harmonize documentation within and across different health care institutions making documentation more efficient and improving scientific data analysis. This work focusses on the field of myeloid leukemia (ML), where a semantic core of common data elements (CDEs) in routine and trial documentation is est...
Randomised controlled trials form the foundation for ‘evidence-based-medicine’, but the results of such research can be relied upon only if it was conducted according to principles and standards collectively referred to as ‘Good Clinical Practice’ (GCP). The GCP was established as a basis both for the scientific and ethical integrity of research involving human subjects and for generating valid...
Good documentation does not necessarily equate to good care. This article explores the potential underpinnings of poor documentation from an ethical decision-making lens. Nursing standards of care related to documentation are reviewed. The internal and external constraints of moral distress are considered, as is moral residue. Finally, the roles of the nurse administrator as well as specific re...
Digitalisation of research data and massive efforts to make it findable, accessible, interoperable, reusable has revealed that in addition an eventual lack description the itself (metadata), reuse is often obstructed by information about datamaking interpretation (i.e. paradata). In search extent composition categories for describing processes, this article reviews a selection standards recomme...
BACKGROUND Effective communication is essential to safe and efficient patient care. Additionally, many health information technology (HIT) developments, innovations, and standards aim to implement processes to improve data quality and integrity of electronic health records (EHR) for the purpose of clinical information exchange and communication. OBJECTIVE We aimed to understand the current pa...
introduction: disaster occurs almost daily in the world and increases the issue of it because of high volume of population, industrialization and acts of terrorism, my country is one of the most unexpected event areas of the world. health care systems encounter special challenges in disaster management, that they include triage and treatment a large number victims and also victims' information ...
BACKGROUND Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. METHODS We examined 50 triage documents before and after a CDS tool w...
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