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Against this suggestion, we note that an independent audit of recorded documentation about decisions on fitness to practise taken at the request of the GMC in 2007 by a team involving one of the authors (CH) found no evidence of assessment criteria being inconsistently applied.
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Among patients with a BMI recorded, documentation of most risk factors was higher in patients with obesity compared with normal weight patients; however, control of risk factors was poorer in obesity than normal weight.
Paans et al., have screened patient records of 341 patients of 10 hospitals in the Netherlands to quantify the accuracy of different aspects of record documentation.
It is possible that a greater health care provider understanding or awareness of gout may influence the extent of medical record documentation of gout, an important determinant that cannot be assessed with the current study.
The data presented provide new insights into the availability of data recorded regarding documentation of care delivered to women in a GP shared-care maternity environment.
We found that no consistent pattern of correlates of medical record documentation quality emerged in this study.
This study provided a novel and valuable glimpse into the quality of medical record documentation of primary care physicians using an electronic medical record system in an ambulatory care setting and enabled the assessment of the correlation between physician and patient characteristics and the quality of medical record documentation.
The percentages of medical-record documentation of limitation decisions were low, a finding that confirms the results of the Ethicus study, which revealed a south-to-north difference regarding the presence of written accounts of such decisions [ 31].
Before examining the data, we selected for analysis five measures from the chart review instrument that we believed were the most important indicators of quality of medical record documentation in ambulatory care.
The odds of medical record documentation of diabetes and renal disease when the patient him/herself does not report these conditions increased with age (with respective odds ratios of 2.59 and 2.16 relative to agreement for each additional 10 years of age).
Table 2 shows the unadjusted rates of fulfillment of the five measures of medical record documentation quality for internists and for pediatricians.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com