Background The main focus of healthcare delivery is to ensure patient safety while
practising evidence-based medicine. While doing so the medicolegal safety of the …

A recent joint publication by the Royal College of Physicians and Royal College of Nursing
raised concern regarding the variability in the organisation and quality of documentation …

Background: A complete, accurate, adequate and timely medical documentation helps in
reducing medical errors and serves as important medical–legal evidence. Objective: To …

Background Good clinical record-keeping is central in ensuring patient safety and effective
communication between healthcare professionals. Poor communication is the root cause of …

Clinical documentation is an integral part of the healthcare professional's job. Good record
keeping is essential for patient care, accurate recording of consultations and for effective …

An operation note is a medicolegal document. The Royal College of Surgeons (RCS) of
England's Good Surgical Practice 2014 (GSP) sets out 19 points an operation note should …

Accurate documentation of patient records is essential for ensuring safe and effective patient
care. Inadequate documentation has been linked to medical errors and adverse events …

Introduction Clear documentation at ward rounds is essential to patient safety. The purpose
of this audit was to identify areas that could be improved in the documentation at surgical …

Aim To assess the quality of neurosurgical electronic discharge documents (EDDs) as per
the Scottish Intercollegiate Guidelines Network's (SIGN) discharge document guidelines …

Background Deficiencies in medical clerking could have significant impacts on patient-
centred care, medico-legal issues and accuracy of medical coding. The latter could have …