PubMed Health⌕ Search

PubMed · 10310611

Setting the stage for improved record content.

Abstract

The quality of the medical record depends, in large part, upon those who document within the record. When documentation is suboptimal, the medical record practitioner must develop strategies to change others' documentation practices. This article describes a technique used to improve record content, and at the same time, make better use of medical record committee time.

Explore related subjects

Keep this discovery

Explore connections, maps & timelines

BibTeXRIS

T J Freeman. 1984. Setting the stage for improved record content.. https://pubmed.ncbi.nlm.nih.gov/10310611/

Cite the original work for its findings. Save a collection to share your selection of sources.

KEEP EXPLORING

Related citations

[Retained foreign bodies from the view of the OR nurse].

Patient safety in the operating room is of high priority for the surgical team and for all healthcare workers involved. Counting procedures contribute to minimizing potential risks for the patients, especially in preventing them from leaving the operating room with retained, unintended foreign bodies. A total of 64% of operating room nurses involved in a survey are reported as having been involved in a surgical procedure in which the correct count prevented foreign bodies from being left in the patient. In addition, the strengths and potential weak points of the counting procedures could be identified. The results of the survey and drafts for a standard counting control as well as procedural recommendations are presented for discussion. A recommendation can be provided for each surgical department in order to check their own counting methods for avoiding potential risks.

Documentation↗