USEFUL DOCUMENTS + REFERENCES
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REFERENCES
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NMC. Record Keeping Guidance (updates 2015). Retrieved from https://nipec.hscni.net/download/projects/previous_work/highstandards_ed...
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RCN. Record Keeping – The Facts (2019). Retrieved from https://www.rcn.org.uk/professional-development/publications/pub-006051
Royal College of Occupational Therapists. Keeping Records Guidance for occupational therapists (2017) 3rd edition. Retrieved from www.RCOT.co.uk
https://www.rcot.co.uk/sites/default/files/Keeping%20records%20-%20guidance%20for%20occupational%20therapists%202017.pdf
RCP. Code of Conduct for Physician Associates. Retrieved from https://www.hmrpca.co.uk/storage/media/content/files/physician-associates/5ae2ea831d971_PA_Code_of_Conduct.pdf
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UK Government. Data Protection Act 1998. 1998. Retrieved from http://www.legislation.gov.uk/ukpga/1998/29/contents
FURTHER READING:
Abdelrahman, W., Abdelmageed, A., 2014. Medical record keeping: clarity, accuracy, and timeliness are essential. BMJ: British Medical Journal 348, f7716. https://doi.org/10.1136/bmj.f7716
Bates DW, Gawande AA. Improving safety with information technology N Engl J Med 2003;348(25):2526-2534Jun 19
Bausi, A., Brockmann, C., Friedrich, M., Kienitz, S., 2018. Manuscripts and Archives: Comparative Views on Record-Keeping. De Gruyter, Inc, Berlin/Boston. https://doi.org/10.1515/9783110541397
Bear, A., Thiel, E., MD MS, 2016. Documentation of Crucial Medical Information in Critically Ill Patients (S756). Journal of Pain and Symptom Management 53, 440–441. https://doi.org/10.1016/j.jpainsymman.2016.12.267
Bragg, D., Voll, J., Maxwell-Armstrong, C., 2013. Teaching medical documentation skills – An innovative method to improve patient care. International Journal of Surgery 11, 699–699. https://doi.org/10.1016/j.ijsu.2013.06.601
Clynch, N., Kellett, J., 2014. Medical documentation: Part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. International Journal of Medical Informatics 84, 221–228. https://doi.org/10.1016/j.ijmedinf.2014.12.001
Fan, V.Y., Hsu, J., 2010. Strengthening medical documentation skills through a focused writing course. Medical Education 44, 1142–1143. https://doi.org/10.1111/j.1365-2923.2010.03807.x
Future of patient records. Care for records for care: an appraisal of the practicalities of electronic patient record. Proceedings of the 8th European Health Records Conference. Maastricht, the Netherlands, May 21–24, 1996.
Grundgeiger, T., Albert, M., Reinhardt, D., Happel, O., Steinisch, A., Wurmb, T., 2016. Real-time tablet-based resuscitation documentation by the team leader: Evaluating documentation quality and clinical performance. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 24, 51. https://doi.org/10.1186/s13049-016-0242-3
Hanson, J.L., Stephens, M.B., Pangaro, L.N., Gimbel, R.W., 2012. Quality of outpatient clinical notes: A stakeholder definition derived through qualitative research. BMC Health Services Research 12, 407–407. https://doi.org/10.1186/1472-6963-12-407
Lenert, L.A., 2016. Toward Medical Documentation That Enhances Situational Awareness Learning. AMIA . Annual Symposium proceedings. AMIA Symposium 2016, 763–771.
Mathioudakis, A., Rousalova, I., Gagnat, A.A., Saad, N., Hardavella, G., 2016. How to keep good clinical records. Breathe 12, 371–375. https://doi.org/10.1183/20734735.018016
McCabe, M., Mason, K., Mink, R., Werner, J., Schneider, J., Tcharmtchi, M.H., Armijo-Garcia, V., Winkler, M., Baker, D., Nassar, D., Turner, D., 2020. 1380: BEST PRACTICES IN MEDICAL DOCUMENTATION: A CURRICULAR MODULE FOR PEDIATRIC INTENSIVISTS. Critical Care Medicine 48, 667–667. https://doi.org/10.1097/01.ccm.0000645436.08036.95
Menachemi, N. Collum, T.H. 2011 Benefits and drawbacks of electronic health record systems, Risk Manag. Healthc. Policy, 4 (2011), pp. 47-55
Narayanan, J., Dobrin, S., Choi, J., Rubin, S., Pham, A., Patel, V., Frigerio, R., Maurer, D., Gupta, P., Link, L., Walters, S., Wang, C., Ji, Y., Maraganore, D.M., 2017. Structured clinical documentation in the electronic medical record to improve quality and to support practice‐based research in epilepsy. Epilepsia 58, 68–76. https://doi.org/10.1111/epi.13607
Peckham D, Whitaker P, White H. (2015) Research in progress-electronic patient records: a new era. Thorax. 70(5):473–475.
Pelto-Piri, V., Kjellin, L., Lindvall, C., Engström, I., Örebro universitet, Institutionen för hälsovetenskap och medicin, 2016. Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden. BMC Health Services Research 16, 66. https://doi.org/10.1186/s12913-016-1310-0
Pourasghar, F., Malekafzali, H., Koch, S., Fors, U., 2008. Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study. International Journal of Technology Assessment in Health Care 24, 445–451. https://doi.org/10.1017/S0266462308080586
Sanderson, A.L., Burns, J.P., 2020. Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation. Critical Care Medicine 48, 579–587. https://doi.org/10.1097/CCM.0000000000004200
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Yeo, G., 2018. Records, information and data: exploring the role of record-keeping in an information culture, 1st ed. Facet Publishing, London.