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8 Medication safety can be compromised during prescribing and administrating due to wrong dose, drug or route; incorrect data entry; inadequate communication; lack of consideration of patient factors such as allergies, comorbidities and multiple medications; and illegible, incomplete or ambiguous documentation.
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However, we encountered many instances of incomplete, ambiguous, and unclear documentation in the chart documents in a manner that appears to have been experienced by other researchers who have tried to document antibiotic timing[ 3, 4, 8, 9, 13, 15, 19, 20].
A formalized protocol was developed for dealing with incomplete, ambiguous and unclear documentation.
We analyze access control mechanisms of the COM+ architecture and define a configuration of the COM+ protection system in more precise and less ambiguous language than the COM+ documentation.
Significantly, "unclear" documentation--reflecting an ambiguous or omitted description of a key HRIS feature and illustrated by the yellow bar--was the most common rating for 11 indicators, and this held true for both crisis and non-crisis countries.
Antibiotics that were documented as given, but without clear chart documentation of the associated timing, were coded as ambiguous-timing.
ICD International Classification of Diseases Information on influenza vaccination was not analysed because documentation in the EMR data is ambiguous.
Data errors can result from incomplete or illegible chart documentation, incorrect data entry, misinterpreted or ambiguous data definitions, and inadequate abstractor training and monitoring [ 6– 8].
Despite the life-threatening cardiotoxic consequences of fluorinated hydrocarbon exposure, the documentation of toxic effects in human subjects is still ambiguous [ 1, 11].
For most methods, such constraints have no formal documentation, and human-readable documentation of them is usually incomplete and ambiguous.
Poor documentation, when it occurred, involved poor handwriting on the MDM proforma or ambiguous annotations, which gave no clear account of the MDM decision.
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CEO of Professional Science Editing for Scientists @ prosciediting.com