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That there are multiple pieces of documentation for the recording of weight (drug chart, medical notes, nursing assessment forms) which are not user friendly.
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These included documentation for the patient's medical record as well as communications to other health care providers.
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.
Particularly, there is a challenge for standardization of recording decision-making processes for the recording and documentation of digital data.
The coding performed was secondary coding, based on the text that was written, and it was done by persons other than the GPs responsible for the documentation in the record entries.
While the case record form (CRF) documentation for the evaluative study was assessed as time consuming, the application of the pathway in practice was rated as time saving, or no difference was recognized.
Make copies of the application and all documentation for your records.
"If Larry did complete the 113 marathons and sends in required documentation for our records management team to review, he will have broken the current record," Sara Wilcox, a Guinness public relations and marketing assistant, told Reuters in an e-mail on Tuesday.
This model promises to improve the documentation in the record and thereby facilitate analysis of records for evidence based medicine as well as cost and policy analyses.
Provide appropriate documentation for the audience involved.
Research has already demonstrated the benefits of electronic documentation for record review, prescription and test ordering, and care management [ 2, 7].
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