title: Patient documentation. On the records.
abstract: Documentation of patient care is frequently the Achilles heel of clinical services. The use of a multidisciplinary, semi-structured healthcare record may achieve improvements, but it needs to be coupled with appropriate strategies to overcome professional and cultural barriers to unified documentation. When implementing changes, clinical staff may overestimate their clinical information needs while underestimating the problems of its routine collection.
authors.affiliation: United Leeds Teaching Hospitals Trust, UK.
authors.forename: E
authors.initials: E
authors.lastname: Renvoize
authors.forename: A
authors.initials: A
authors.lastname: Grange
authors.forename: J
authors.initials: J
authors.lastname: Pinder
authors.forename: A
authors.initials: A
authors.lastname: Mavor
authors.forename: G
authors.initials: G
authors.lastname: Almarow
authors.forename: M
authors.initials: M
authors.lastname: McGowan
mesh_terms: D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D011786:Quality Control; D013222:State Medicine / Q000458:organization & administration; D006113:United Kingdom