Legal Aspects of Documenting Patient Care

Scott, Ronald W.

doi:10.1097/00003465-199505000-00010

Cited by 4 publications

(4 citation statements)

References 0 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Such a central document also clearly has medicolegal implications if incomplete or incorrect. This has been previously demonstrated in the documentation of risk (Elbogen et al, 2003), but is also relevant to other aspects of assessment, as well as the general documentation of patient care (Scott, 2000).…”

Section: Discussionmentioning

confidence: 70%

Psychiatric admission booking: audit of the impact of a standardised admission form

Dinniss¹,

Dawe

Cooper³

2006

Psychiatr. bull.

View full text Add to dashboard Cite

Aims and MethodWe used a complete audit cycle to assess the quality and completeness of current admission bookings by junior doctors and whether the introduction of a standardised admission form led to improvements.ResultsFollowing the introduction of the standardised form significant improvements were found in almost all areas, including the recording of basic data, history, mental state, physical examination, risk assessments and diagnosis.Clinical ImplicationsThe introduction of a standardised admission form improved the completeness of information obtained. The form may also be used as an educational tool and to assist trainees preparing for examinations.

show abstract

Section: Discussionmentioning

confidence: 70%

Psychiatric admission booking: audit of the impact of a standardised admission form

Dinniss¹,

Dawe

Cooper³

2006

Psychiatr. bull.

View full text Add to dashboard Cite

show abstract

“…Furthermore, documentation may be a means for facilitating ethical behavior. Much literature related to documentation seems to focus on using documentation to protect mental health professionals in case of a legal suit (Gross, 2001;Scott, 2000;Woody, 2001). In documentation used for this purpose, counselors document what they have done related to the diagnosis, provide a rationale as to why they did it, provide some idea of the impact of what they did, and indicate what was discussed with clients prior to gaining their consent to act.…”

Section: Traditional Strategies For Facilitating Ethical Diagnostic Pmentioning

confidence: 99%

Ethical Dimensions of Diagnosing: Considerations for Clinical Mental Health Counselors

Kress

Hoffman

Eriksen

2010

Counseling and Values

View full text Add to dashboard Cite

There are numerous ethical considerations inherent within the process of assigning a Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000) diagnosis. In this article, general ethics considerations such as informed consent and confidentiality, accuracy of diagnosis, and multiple relationships are examined as they relate to clinical mental health counselors' use of the DSM‐IV‐TR. The article concludes with the authors' suggestions for ethically sensitive diagnostic practices.

show abstract

“…A study conducted in South Africa indicated that pharmacists could not read a quarter of the prescriptions and most of the prescriptions lacked the essential features 4 . In Kenya, prescription errors are widespread and the use of generic names is low 19,20 . One possible reason for the increased use of brand names is that the rise in the number of generic drugs in the pharmaceutical sector has led to increased competition, which has forced pharmaceutical companies to target health prescribers 18 .…”

Section: Introductionmentioning

confidence: 99%

“…4 In Kenya, prescription errors are widespread and the use of generic names is low. 19,20 One possible reason for the increased use of brand names is that the rise in the number of generic drugs in the pharmaceutical sector has led to increased competition, which has forced pharmaceutical companies to target health prescribers. 18 Pharmaceutical companies influence health prescribers to promote their products through a visit by a medical representative, who issues gifts and drug samples.…”

Section: Introductionmentioning

confidence: 99%

Handwritten prescription practices in a public hospital in Uasin Gishu County, Kenya: a best practice implementation project

Amdany,

Kiprop

2023

JBI Evidence Implementation

View full text Add to dashboard Cite

Background: Prescription writing error is a common phenomenon in the health sector. Appropriate handwritten prescription practices minimize medical errors during medical drug dispensing. Objectives: This project aimed to identify the extent to which clinicians adhere to handwritten drug prescription best practices and implement evidence-based strategies to improve compliance with handwritten prescription best practices in an outpatient department. Methods: The project was conceptually informed by the JBI Model of Evidence-Based Healthcare and the JBI Evidence Implementation Framework. Baseline and follow-up audit data were collected and analyzed using JBI's Practical Application of Clinical Evidence System (PACES) software. The JBI Getting Research into Practice (GRiP) program was used to identify potential barriers and design intervention strategies. The project was conducted in a public hospital outpatient department in Uasin Gishu County, Kenya. Results: There was a 100% improvement in compliance with the number of prescribers who had received education on essential features of a handwritten drug prescription. High compliance was observed in prescriptions that indicated the patient name (99%) and date of prescription (98%) in the follow-up audit. Approximately half of the prescriptions included a diagnosis of the disease in both the baseline and the follow-up audit. However, in the follow-up audit, only 21% of the prescriptions had legible handwriting and 27% prescribed drugs using the generic drug name. Conclusion: Regular audits and dissemination of audit findings through continuous medical education, hospital communication forums, and notices improved compliance with the number of prescriptions that contained the patient identifier and the date of prescription.

show abstract

Legal Aspects of Documenting Patient Care

Cited by 4 publications

References 0 publications

Psychiatric admission booking: audit of the impact of a standardised admission form

Psychiatric admission booking: audit of the impact of a standardised admission form

Ethical Dimensions of Diagnosing: Considerations for Clinical Mental Health Counselors

Handwritten prescription practices in a public hospital in Uasin Gishu County, Kenya: a best practice implementation project

Contact Info

Product

Resources

About