Departmental collaborative approach for improving in-patient clinical documentation (five years experience)

International Journal of Pediatrics & Adolescent Medicine
Eyad AlmidaniSaleh Almofada

Abstract

Health care institutes are cooperative areas where multiple health care services come together and work closely; physician, nurses and paramedics etc,. These multidisciplinary teams usually communicate with each other by documentation. Therefore, accurate documentation in health care organization is considered one of the vital processes. To make the documentation useful, it needs to be accurate, relevant, complete and confidential. The aim of this paper is to demonstrate the effect of the collaborative work in the Department of Pediatrics on improving the quality of inpatient clinical documentation over 5 years. Improving clinical documentations went through several collaborative approaches, these include: Departmental Administration involvement, establishment of quality management team, regular departmental collaborative meeting as a monitoring and motivating tool, establishment of the residents quality team, Integration of quality projects into the new residents annual orientation, considering it as a part of the trainee personal evaluation, sending reminders to the consultants and residents on the adherence for admission note initiating and 24 h's verification, utilization of standardized template of admission note and progr...Continue Reading

Citations

Mar 5, 2020·Journal of Healthcare Risk Management : the Journal of the American Society for Healthcare Risk Management·Leah M SchmitzCynthia J Stives

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