The audit checklist included information on the process and outcome of care as per guideline recommendations, such as treatments prescribed, documentation of family history, smoking and physical activity, recording of blood pressure, BMI and waist circumference in physical examination and investigations ordered - ECG, Creatinine, HbA1C, lipid profile, and TSH.
Omitted items were identified after reconciliation on admission or after comparison with earlier inpatient prescribing documentation, and their inclusion in the denominator ensured that pharmacists were able to determine whether items were omitted for a valid clinical reason before recording them as a PE.
We examined six areas: prescribing support, disease management, clinical documentation, work practice, preventive care, and patient-physician interaction.
We organized the studies into six topic areas: prescribing support, disease management, clinical documentation, work practice, preventive care, and patient-physician interaction.
For example, the overuse of antibiotics in upper respiratory infections might be targeted by an alert if an antibiotic is prescribed when documentation does not warrant it or by a smart form that guides documentation and therapy selection.
Paragraphs (d)(1) through (12) of this section also prescribe additional documentation requirements that must be met in certain cases in order to treat a payee as having a specific chapter 4 status and specific standards of knowledge that apply to a particular payee, in addition to the general standards of knowledge set forth in paragraph (e) of this section.
A subset of procedural tasks is administrative (e.g. prescribing orders, documentation, scheduling imaging studies).
Oxygen treatment for pneumothorax should be viewed as a prescribed drug, with documentation for its indication, target saturation and titration goals.
Indeed, RIF should only be prescribed after definitive bacteriological documentation, and should systematically be associated with another effective molecule, thereby reducing the risk of emergence of RIF-resistant staphylococcus mutants.
Often, the documentation prescribing how to act in the event of a breach is out of date, inaccessible to key decision makers, generic, unhelpful for guiding specific activities, or some combination of the above.
Illegible prescription and medical note documentation, prescribing using incorrect sections of the prescription chart and failure to record medication administration contributed to slips, mistakes and violations when nurses decided against or omitted looking at these or misinterpreted their meaning.
