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The quality of cause-of-injury data: where hospital records fall down

Kirsten McKenzie1, Leith Forbes Harding, Susan Mary Walker

  • 1National Centre for Classification in Health, Queensland University of Technology, Queensland. K.Mckenzie@qut.edu.au

Abstract

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Purposes:
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Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.