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We devised a method to split clinical data into documentation categories and packages which are completed in one treatment encounter by one person.
The category documentation involves questions about substance identification and/or literature reports about clinical effects.
Thirty-eight out of 100 questions concerned the category documentation (substance identification and/or literature reports about clinical effects), 36 interactions, 16 adverse effects, 9 pregnancy and lactation, and 1 question concerned contraindications.
* only division in main categories documentation and communication possible.
Across all weight categories, documentation of discussion of exercise, breastfeeding and pain management occurred in less than a fifth of charts.
Sub-analysis of the impact of diabetes status on CKD documentation within each eGFR category was performed.
For 84-85% of people it was possible to determine the category from documentation in clinical record or through the auditor applying an algorithm based on data in the clinical record.
To exploit the maximum precision of the ICF categories for documentation in specific contexts, scholars have advocated using the more accurate third or fourth category levels.
There are substantial benefits from the first few phases: alignment to IT, education of business leaders, statement of a future vision, and documentation of critical information categories.
Indirect and direct patient care and documentation were additional major categories of tasks.
Therefore, a "land settlement" leading to a proper documentation of ownership and categories is required.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com