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Documentation of an artificially maintained temperature on an observation chart without reference to Thermogard XP® activity has implications for both immediate patient management and retrospective review of observation charts for audit or medico-legal purposes.
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Of the 100 medical charts audited in Phase 1 two charts were missing and four did not have a PHR filed within (PHRs are usually filed in the hospital chart at delivery) leaving a total of 94 charts available for audit.
Patient charts were identified for audit by a pharmacy-generated insulin list.
At each site, five medical and five surgical charts were selected for audit from fiscal year 2004 from each of three age groups: 29 365 days, 366 days to 5 years and over 5 years; 10 charts were randomly selected from the fourth age group of 0 28 days.
A simple random sample was used to select 10% of patient charts for an EMR chart audit to verify the accuracy of abstracted data.
In addition, only one hospital site, namely Sunnybrook hospital, was selected for chart audit.
Moderate increases in CPG compliance has been derived from a combination of chart reminders and chart audit interventions [ 13, 14].
The authors wish to acknowledge Dr. Arjuna Ponnampalam for performing the chart audit for the validation study.
Charts were audited for participant characteristics, a range of diabetes quality care indicators derived from clinical practice guidelines (CPG) [ 14], pharmacologic treatment and the presence of co-morbidities that are defined and described in more detail elsewhere (12).
The research coordinator initially audited ten charts for each service in two practices and reviewed this with the principal investigator.
In Senegal, clinical audits of charts for all pregnant women with hemorrhagic and hypertensive complications also promoted correct diagnosis and treatment [ 25].
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