We developed and tested a set of four QIs for medical records (record conformity, traceability of pain assessment, screening for nutritional disorders, and time elapsed before sending discharge letters) and collected data in a panel of 36 volunteer hospitals.
Four QIs based on medical records were tested: medical record conformity; traceability of pain assessment; screening for nutritional disorders; time elapsed before sending copy of discharge letter to the general practitioner.
The lack of records has serious implications on traceability of diseases and veterinary drug use, thus affecting international safety requirements.
If the patient is unconscious, whether they are at the end of their life or not, the procedure of limitation or arrest of treatment has to satisfy three requirements: respect of the individual will of the patient; dialogue and medical collegiality; and traceability of all decisions in the medical record.
aNumbering is retained from automatic numbering on the recording device in order to maintain traceability of evidence.
5) The traceability of the variables monitored during IHT must be specifically recorded on a monitoring sheet that must subsequently be integrated into the patient's medical file.
The product traceability of biologics is routinely ensured within the individual patient's pharmacy records; while variable product information, such as the product batch number, is conversely expected to be infrequently captured in dispensing records at present [ 21].
An extensive network of hospitals and primary healthcare centres are operated by the VHA, sharing an electronic medical record with an advanced electronic prescription system that includes the traceability of the prescription (from prescription by the doctor to the dispensing of the drug in pharmacies and subsequent claims to the VHA).
Because of this, in 2013, the summary of product characteristics, or label, of two biologic products was altered to include the statement "in order to improve the traceability of biological medicinal products, the trade name of the administered product should be clearly recorded (or stated) in the patient file" [ 35, 36].
In anticipation of biosimilars of the mAb rituximab, Section 4.4 of the MabThera (rituximab) SPC was revised to read "in order to improve the traceability of biological medicinal products, the trade name of the administered product should be clearly recorded (or stated) in the patient file".
