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Again, it is unlikely that documentation omissions were distributed differently between RA and non-RA cases; therefore, bias is unlikely.
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Documentation inaccuracy or omission usually surrounds items that residents feel uncomfortable managing; such as vascular lines and medications.
48 Furthermore, participants may grow weary of recording over time, leading to cursory documentation and/or food omission.
One hundred and thirty seven (5%) patients had one hundred and ninety nine omissions in documentation or radiotherapy prescription.
As expected with any new process, some omissions in documentation were observed with large variations from nurse to nurse.
None of the omissions in prescription documentation were considered harmful to the patient because the actual three-dimensional radiotherapy plan was assessed and approved separately on a radiotherapy planning terminal and there were no errors in this section noted.
Does omission of pain documentation represent an assumption that pain management lies outside the remit of the doctor role, or perhaps reflects a lack of education?
The most significant omission is supporting documentation.
Overall, 75% of omissions were lack of documentation of investigations, either radiology or pathology.
Of these omissions, 105 were inadequate documentation or filing of investigation results (53%).
In our study, of the 2597 radically treated patients, the rate of omissions in radiotherapy prescription and clinical documentation, including filing of radiology and pathology source documentation was low.
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CEO of Professional Science Editing for Scientists @ prosciediting.com