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To develop guidelines for the documentation elements that need to be included in any record of pharmacist-provided care to allow the quality of the care to be assessed and to describe the use of these guidelines to improve the quality of pharmacist documentation.
Not only were there significantly more AAACN documentation elements present in the CDS triage records, the CDS documentation had more symptom features listed that could justify the disposition.
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We then compared traditional and intervention care in terms of the presence of each type of documentation element.
Therefore, code review, version control, and thorough documentation are important elements for effective transparency [81].
The most relevant work to ours is done by Yeh et al. [38].They develop a system called Sikuli that enables users to search a large collection of online documentation about GUI elements using screenshots.
In situations where conflict between physicians and substitute decision makers leads to a submission for Consent and Capacity Board review, appropriate documentation of the elements required for consent to life sustaining therapy will be essential.
In the present study, deficiencies in pre-printed documentation of airway elements in the anaesthesia records were observed; for example, for mask ventilation and the number of intubation attempts.
To determine whether a basic fall evaluation was performed, reviewers search the medical record for documentation of five elements: 1) circumstances of the fall, 2) medications the patient is taking, 3) relevant chronic conditions, 4) diagnostic plans/therapeutic recommendations, and 5) documentation of action taken as appropriate.
Images were taken with a Olympus HamburgGermanyany) DS-Ri1 microscope, an Nikon (Melville, NY, USA) BX41 camera and NIS-Elements documentation software.
The ability to create a coded problem list is a requirement of the Certification Commission for Health Information Technology (CCHIT) for all certified electronic health record (EHR) systems [ 2] and problem documentation is an element of Joint Commission requirements [ 3].
It also happens to be a foolproof documentation of every element involved in the process.
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com