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A document-based review of treatment in outpatient services
1South West Health Region, NSW Department of Health, Griffith.
Objective:
To determine criteria for Accident and Emergency outpatient documentation, to review current practice and to overcome identified deficiencies.
Method:
Retrospective criteria audit of 160 records from a random sample of outpatient attendances over one week at four hospitals. The distribution to medical and nursing representatives of questionnaires accompanied by the audit results.
Results:
The overall standard of outpatient documentation was high. Problem areas included the recording of cause of injury, significant laboratory and radiological findings, discharge instructions and time of disposal. Forms design was criticised by some users. Overall, however, non-compliance was seen to be less of a problem than lack of awareness by staff of what is important to document in an outpatient setting.