Objectives: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR). Methods: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire.in a teaching and district general hospitals. Results: Four hundred new urology patient consultations, 11 clinicians...
Keywords: medical record, structured form, documentation, audit, proforma, out-patient
01/2005 | Methods of Information in Medicine, SchattauerA large body of evidence attests that quality programs developed around the analytical phase of the total testing process would only produce limited improvements, since the large majority of errors encountered in clinical laboratories still prevails within extra-analytical areas of testing, especially in manually intensive preanalytical processes...
Keywords: audit, detection of unsuitable specimens, extra-analytical variability, guidelines and consensus recommendations, laboratory errors, specimen collection
06/2007 | Clinical Chemical Laboratory Medicine, Walter de GruyterThe requirements of ISO 15189:2003 are discussed in the context of a process- and outcome-based quality management model in which the user's needs are the central focus...
Keywords: audit, continual improvement, management review, procedures, process, quality management
06/2006 | Clinical Chemical Laboratory Medicine, Walter de Gruyter