To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems.
The authors found that the SHSurgAdN was comparatively deficient in the documentation of the relevant system examination and the cardiorespiratory examination, and that this deficiency had worsened over the intervening 4 years.
Documentation errors were deemed to have occurred when there were missing or inadequate documentation of history, examination, diagnosis in the medical records or problems of illegibility.
Each US that is performed, used to make clinical decisions and are subsequently submitted for reimbursement require appropriate documentation regarding the indication for the examinations, written interpretation of the examinations, description of the organs or structures studied, who performed the examinations, and documentation of the scope of the study [13].
We also investigated whether there was documentation of particular examination observations, positive or negative.
- Standardised documentation of physical examination, laboratory findings, and diabetes complications in a DMP-form once a year.
In an increasingly paperless National Health Science, an electronic equivalent could be introduced into outpatient templates; a pop up box, once documentation of intimate examination is entered, may be effective.
There are currently no evidence-based standards for best practice concerning adequacy of documentation of physical examination findings for Wellington Hospital, neither are there any clinical guidelines derived from expert opinion.
Documentation of medical examination (see below).
Although both BIO and WFDI with the RetCam120 were recommended in our study protocol, no systematic documentation of the actual number of dual examinations is available from the NICUs outside Regensburg, nor concerning the order of examinations, i.e. BIO first or digital imaging first.
A series of training sessions was conducted with the three study Physical Therapists to discuss the content of the examination form, standardize documentation procedures and develop a consensus for performing special tests.
