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To assess the quality and completeness of record keeping in CARDSS, we did an audit of data in each participating centre during or at the end of the trial.
Missing data is a problem in many other settings, even in more affluent countries, but one of the purposes of the database was to help the team measure up to international standards, and efforts are being made to ensure completeness of record keeping.
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The completeness of the medical records, the standard of record keeping and obstacles to retrieving charts also indicate a serious problem that needs due attention from clinicians and data personnel.
However, the pattern of available data between the two records does suggest the mode of record keeping does influence the completeness of data captured.
Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors.
In addition, the reviewers will also evaluate the quality of the record keeping and the completeness of the transfer of information in the patient record.
"It's a lot of new record keeping with not a lot of additional environmental benefit".
I cannot speak to the adequacy of their record keeping".
For the practice style independent fields we agreed that visit documentation (documentation for the purposes of clinical record keeping) and allergies were clinically the most important for patient safety and thus a benchmark of 95%% data completeness was set.
First, we were unable to review all hospital admissions records because of incomplete record keeping.
The importance of documentation and record keeping is paramount.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com