Second, the use of hospital medical records may have limited our ability to capture all the patients' documented conditions as this is affected by the quality of documentation.
This is a 6-graded ascalementhatale that combines clinical and pharmacological aspects with the quality of documentation.
89% of the surgical team felt the form improved quality of documentation and preferred its use to freehand clerking.
On the one hand, there is a lack of a comprehensive model to evaluate the quality of documentation.
MedEye is a turn key solution to stop and prevent medication errors, and at the same time improving quality of documentation and saving nurses time in the complete medication process," he adds.
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.
Our study demonstrates that a standardised surgical clerking proformas improves the quantity and quality of documentation in comparison to freehand clerking, is preferred by health professionals and improves reliability of the audit quality control process.
The method addresses three different dimensions: (1) Quality management, which evaluates the fulfilment of Users Requirements, and the Users' satisfaction with the existing functions; (2) Usability assessment, which includes a Usability inspection, and a Usability test; (3) Performance evaluation, which assesses the exhaustiveness and quality of documentation.
We measured the quality of documentation as the percentage of essential items contained in the medical record and discharge instructions, the percentage of appropriate testing and treatment decisions, median charges per patient visit, physician satisfaction by pre-experiment and postexperiment questionnaires, and patient satisfaction by telephone questionnaire.
Though the quality of documentation may have impacted on our assessment, we believe these findings accurately represent the management practices in these settings.
The quality of documentation also improved considerably over time.
