Background: Medical records, encompassing patient histories, progress notes, and more,
play a crucial role in patient care and treatment, healthcare communication, medico-legal …

Background Accurate clinical documentation (CD) is necessary for many aspects of modern
health care, including excellent communication, quality metrics reporting, and legal …

BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and
medico-legal consequences. Studies indicate that teaching programs in this field can …

Introduction Physicians recognize the importance of clinical documentation for accuracy of
coding and billing, but it is emphasized little in residency curricula, with an even smaller …

Considering the integral role of understanding users' requirements in information system
success, this research aimed to determine functional requirements of nursing information …

Este estudo objetiva analisar prontuários odontológicos utilizados na graduação em
odontologia no Brasil, considerando sua adequação à legislação e diretrizes éticas em …

Purpose Data comprise one of the key resources currently used in organizations. High-
quality data are those that are appropriate for use by the customer. The quality of data is a …

We investigated the effects of reinforced audit and feedback on the medical record
documentation (MRD) of 35 surgical residents at a tertiary university hospital. In three …

Abstract Objectives Hospital Episode Statistics data are used for healthcare planning and
hospital reimbursements. Reliability of these data is dependent on the accuracy of individual …

Purpose Age‐related macular degeneration (AMD) is a major cause of vision loss. This
study investigated whether performing clinical audit and receiving analytical performance …