Articles for tag: communication, documentation, GMC, records, standards

The Documentation Dilemma: When Too Much Meets Too Little

Medical documentation has become a flashpoint in healthcare, pitting the ideal of comprehensive record-keeping against the brutal realities of overloaded systems. Clinicians find themselves trapped between conflicting demands: create detailed, bulletproof notes that capture every clinical decision and patient interaction, or prioritise direct patient care in a system perpetually short on time and resources. This …

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Reading the records

The delivery of healthcare is complex business.  Often times records are compiled by large numbers of people in teams or extension of teams about a single patient. The vast majority of Electronic Health Records (EHRs) are text-based. Understanding a patient’s condition(s) and needs from records is often demanding of time, effort and concentration. Overall, both …

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Documentation

All health service personnel who deliver or are involved in delivering frontline health services are required to document their work. This is must be at the core of all health care. Follow-up topics: The Documentation Dilemma: When Too Much Meets Too Little and Documentation 2.0. While the publisher and author(s) have used their best efforts …

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