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Chart abstraction included review of physician notes, consultation reports, and laboratory results included in patients' medical records.
The entire chart was examined in duplicate, including the cover page, discharge summaries, admission notes, consultation reports, physician orders and diagnostic reports.
We expect to identify different types of healthcare provider clinical notes from multiple professions and specialties including interdisciplinary progress notes, consultation notes, transfer notes and admission notes.
Electronic medical records were considered adequate to assess risk factors if the clinical notes (progress notes, consultation notes, discharge summaries) documented the medical history, coexisting illnesses, and medication regimens, including use of antimycobacterial agents.
These notes contain free-text from a wide variety of sources including point form progress notes, consultation letters from different practitioners in a variety of specialties, diagnostic test results, pathology reports and hospital discharge summaries.
Then the reviewers extracted data independently for evidence of PSIs through an examination of the entire chart, including the cover page, discharge summaries, pathology reports (including autopsy reports), trauma and resuscitation records, admission notes, consultation reports, surgery/operative reports, anaesthesia reports, interdisciplinary progress notes and physician daily progress notes.
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As in previous studies [ 24], a detailed review of progress notes, consultations, laboratory and pathology reports, and additional relevant data in the records were reviewed to evaluate the diagnostic process and assess it for MDOs.
It is important to note while broad data collection from referral notes, consultations, observational notes and questionnaires offer an overview of services, they cannot provide the impressions of parents and children, and of those working within and referring into this service.
It would appear vital therefore that training in the management of the fit note consultation emphasises the importance of the GP role and how GPs can make best use of the time available to them.
Also of note, consultation of medical records indicated that the majority of PHN patients (59.2%; n = 90) had received an antiviral during the treatment of their initial HZ episode.
Six themes were identified: changing the format and method of completing the fit note; completion of the fit note; the fit note consultation process; workplace management of the fit note; communication between GPs and employers about patients' fitness to work; promoting and supporting best practice in fitness use.
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