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PubMed · 12931506

Documentation errors are easy to avoid and correct.

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DocumentationGuidelines as TopicInformation ManagementMedical RecordsMedical Records Department, HospitalQuality ControlUnited StatesJournal Article

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2003. Documentation errors are easy to avoid and correct.. https://pubmed.ncbi.nlm.nih.gov/12931506/

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PubMed2004

[Erroneous and unsatisfactory filling in of drug charts--a potential source of medication error].

BACKGROUND: Medication errors may have serious consequences for patients and erroneous drug charts represent one of several causes of error. As part of a quality assurance survey, we studied whether user documentation on the charts was in accordance with the guidelines for chart keeping. MATERIAL AND METHODS: On the same day, the drug charts of all hospitalized patients (n = 401) were copied and a representative sample of 207 charts was reviewed. RESULTS: 15 charts had no prescriptions; 14 of the remaining 192 charts (7 %) were correctly filled in. 152 charts (79 %) had deviations that we considered might pose only minor potential health risk; 26 (14 %) had deviations implying potential risk. No charts had deviations considered to pose major risk. INTERPRETATION: Several deviations from the guidelines were found and better training is needed; we recommend standardisation of drug charts and guidelines.

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