Within Singapore, there is a need for clear documentation of the capabilities and standards of service to be expected from its EDs.
The uptake of this checklist has not been optimal, but the MSC provides an excellent tool for clear documentation of C-spine status.
However, the differences between the cohorts in both admission diagnosis and mobilisation practises highlight the need for clear documentation of baseline practise before implementation of any change process.
The proportion of people who had clear documentation of risk classification, and for whom the auditor did not need to apply the algorithm, increased from 56% (87/154) in 2008 to 71% (103/145) in 2009 and 76% (118/156) in 2010 (p < 0.001).
Identified areas for improvement include clear documentation of a process of exclusion of other diagnoses, and prophylaxis for potential treatment complications, including osteoporosis and gastric symptoms.
Provider orders for antibiotics should include clear documentation of the drug, dose, duration and indication.
Of the 80 patients for whom there was clear documentation of severe dehydration in the clinic record, all received IV fluids and 74 (92.5%) also received ORS.
Some journals [ 15- 17] already require the use of these specific section headings for RCTs to encourage clear documentation of key considerations.
These included: clear documentation of clinical notes reduced consultation and waiting times decision support for prescribing medications, including reminders, allergy warnings, and information about drug interactions alerts for abnormal laboratory results facilitation of data provision for national outcome monitoring.
If taken regularly, psychostimulants continue to be effective for two to five years, although clear documentation of long-term benefit remains elusive [ 2- 4].
