In both the Brighton and Cardiff scores, the documentation charts were modified to better capture the score items and consequently might have influenced treatment decisions (perhaps appropriately), thus increasing apparent score performance [ 27, 28].
In order to explore reasons for non-documentation, charts were re-examined and a pharmacist history was identified in only (n = 45, 51%) of patients while the nursing and physician histories were available in all patients.
The remaining indicators measuring compliance, as well as six indicators measuring documentation by chart review, showed a compliance below 80%% before and after e-learning.
The classes focused on managing patient-level information using problem lists and medication lists, as well as efficient documentation and chart review.
There is plenty of documentation - charts, maps, crosstables, photographs - to cover the period marred by World War I that put many chess careers on hold.
Our classification of "improvement" relied on clinician documentation in charts, and it is possible that changes in lesion size, lesion number, or edema were not consistently documented in the medical record.
The share of documentation and charting activities is also of interest.
Patient endorsement of question 3, expressing fear for safety, was associated with safety planning documentation in charts.
Although this approach reduced the information bias during documentation, incomplete charting could lead to gaps in knowledge.
It will be completed following annual site visits by a team of external assessors who observe team meetings, review documentation and charts, and interview staff and participants.
