Challenges in medical record documentation: Insights from nurses and physicians
Keywords:
Documentation in healthcare, medical records, documentation issues, documentation reliability, healthcare organizational design and economy, Electronic health record systems, data sharingAbstract
Background: Documentation in the patient’s clinical record is central to safe and quality patient care. Nevertheless, working in the framework of this or that health care, the professionals have several obstacles that affect Its effectiveness and reliability; these are insufficient documentation, strict deadlines, and the use of modern technologies. Aim: The focus of this proposed study is to establish practical identification of typical documentation problems faced and seek means of addressing them with enhanced precision in health care organizations. Methods: Mail survey on documented professionals and a sample of recent research in the field was used to ascertain documentation concerns and possible solutions such as new technology and training programs. Results: Specific factors that were proposed include time constraints, inadequate documentation, variation in terminology, and data integration problems with electronic health records (EHR). The measures like improved standard, better technologies, and professional training has been considered as ideal solution for these challenges. Conclusion: Challenges to documentation can be overcome by improving the standards for documentation and training and integrating new technologies in to address medical record issues to also improve both workflow and patient care.
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