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One of the limitations of this study was that the data were collected retrospectively therefore the results not only reflect the processes of care, but also were reliant on the quality of documentation.
Second, the accuracy of measures is dependent on the quality of documentation in the patient record.
b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course.
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Despite the importance of documentation to clinical care, there is no agreement in the literature on a comprehensive definition of the quality of documentation within a clinical note.
SMR01 entries are carried out by coders who have no direct link to clinical teams but rely on hospital discharge letters, thus the quality of the data is dependent on both the quality of documentation and the experience and expertise of the coder.
Our study also raises issues about the quality of documentation on the identification and subsequent supply of antibiotics to contacts.
In addition, the quality of documentation on discharge summaries was poor, resulting in missed test results 33-633 %), inadequate treatment or hospital course details (7-22 %), non-provision of discharge medications (2-40 %), no test results pending at discharge (65%%), no patient or family counselling 90-922 %) and no follow up plans (2-432-43% 12].
On the one hand, there is a lack of a comprehensive model to evaluate the quality of documentation.
Though the quality of documentation may have impacted on our assessment, we believe these findings accurately represent the management practices in these settings.
This is a 6-graded ascalementhatale that combines clinical and pharmacological aspects with the quality of documentation.
The quality of documentation also improved considerably over time.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com