… 9 terminology, and to abide by the documentation guidelines were noted as a source of
error… on medical record documentation and coding quality. Documentation guidelines are still …

… Proper documentation of clinical record is of paramount importance 5. Self-assessment …
record keeping 6.This study aims at assessing the accuracy of medical record documentation of …

… Background: Medical record document explains all the details … record department at our
medical college affiliated tertiary care … various parameters of medical records such as consent, …

… 50% of hospital medical records … records contained mechanism of falls injury information,
16% contained insufficient details, indicating a deficiency in medical record documentation …

… patient file documentation process. Managing proper documentation and hospital records
addresses the specific issues involved in managing clinical and non-clinical hospital records…

… documentation in a patient’s hospital record includes all information that relates to the care of
the patient during their hospital … documents in the patient’s record because it represents the …

… How nurse experience influences the patterns of electronic medical record
documentation in an intensive care unit. Proc Hum Fact Ergon Soc Ann Meeting 2019;63(1):708-12. …

… documented information on paper records carried from one location to another. However, with
the introduction of electronic health records (… of communication for tertiary hospital that can …

… of documentation of medical records, this … documentation which is the need of the hour. 5
So our study helps in identifying various deficiencies in the documentation of medical records …

… Hospital. This study will endeavor in assessing the existing medical record keeping practice
in tertiary level hospitals of … Documentation and coding of medical records in a tertiary care …