Variables associated with completeness of medical record documentation in the emergency department.

Fiona Wy LaiJoyce A KantMahesha Hk DombagollaAndreas HendartoAntony UgoniDavid McDonald Taylor

Published in: Emergency medicine Australasia : EMA (2019)

Documentation completeness is less among senior doctors, headache patients and for examination findings. Research should determine if the supervision responsibilities of senior doctors affects documentation and if medico-legal and patient care implications exist.

Keyphrases

emergency department
electronic health record
end stage renal disease
advance care planning
newly diagnosed
ejection fraction
healthcare
chronic kidney disease
peritoneal dialysis
prognostic factors
medical students
patient reported outcomes