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PubMed · 15349064

Applied technology rounds out e-documentation.

April V Hamilton·Geraldine A Coyle·Mary G Heinen
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Abstract

Highlights of an electronic healthcare record include clinical reminders, progress note templates, and a clinical reference system.

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DocumentationElectronics, MedicalHumansNursingPreventive Health ServicesPublic Health InformaticsTechnologyJournal Article

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April V Hamilton, Geraldine A Coyle, Mary G Heinen. 2004. Applied technology rounds out e-documentation.. https://doi.org/10.1097/00006247-200409000-00014

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[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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