The assessment of substances under REACH conducted in the German Environment Agency is supported by the knowledge-based system KnowSEC, which is used for the screening, documentation, and decision support when working on chemical substances.
Real-time documentation on decision logs can track progression over time, and could be incorporated into electronic health records.
Documented as both completed and declined or too late on first page of antenatal record, but no documentation confirming decision elsewhere in chart.
The IRAT is useful for identifying key gaps in knowledge, focusing risk management efforts, and providing clear documentation of decision rationales.
CDS – computerized clinical documentation system Decision Support Database – a collection of information about the patients that the clinician's have decided to save in order to ask global questions about groups of patients.
The KnowSEC system is mainly used in three general areas during the assessment of chemical substances: The documentation of decisions (automatically or manually derived), the provisioning of substance overviews and their corresponding states, and for decision support during the assessment.
This procedure enables a reuse of terminology for documentation and decision-support.
An operative note is indispensable to physician documentation and decision-making; however, there are no accepted standards for operative note content.
Documentation of decisions is poor but similar to that reported by others [ 11, 14, 30].
Their concern, therefore, concentrates on the handover, communication and consistent documentation of decisions within the Trust.
Thus, cancer teams follow national guidance which sets out prescribed features of MDT meetings with respect to structure, attendance, documentation of decisions and administrative support.
