Improving paediatric tuberculosis and HIV clinical record keeping: the use of audit and a structured pro forma in a South African regional level hospital

2013 ◽  
Vol 44 (2) ◽  
pp. 96-99 ◽  
Author(s):  
Anu Goenka ◽  
Medeshni Annamalai ◽  
Barnesh Dhada ◽  
Cindy R Stephen ◽  
Neil H McKerrow ◽  
...  
Keyword(s):  
South African ◽  
Regional Level ◽  
Clinical Record ◽  
Record Keeping ◽  
Pro Forma ◽  
Level Hospital ◽  
Paediatric Tuberculosis

scholarly journals 964 Telemedicine: Speedy Triage Tool or Clinical Record?

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A Ghareib ◽  
Z Vinnicombe ◽  
G Visser ◽  
A Ra ◽  
M Mantella ◽  
...  
Keyword(s):  
Plastic Surgery ◽  
Compliance Rate ◽  
Clinical Record ◽  
Portal System ◽  
Clinical Documentation ◽  
University Hospitals ◽  
Record Keeping ◽  
Clinical Document ◽  
National Guidance

Abstract Introduction St. George’s University Hospitals NHS Foundation Trust is a tertiary plastic surgery centre serving a population of 3.5 million in and around South West London. Telemedicine Referral Image Portal System (TRIPS) is integral to our service, allowing triage of patients in remote locations. During Covid, TRIPS helped in reducing footfall and streamlining out of hospital referrals to reduce unnecessary transfer. The aim of this project was to assess the quality of clinical documentation for emergency referrals to plastic surgery via TRIPS. Method We performed a retrospective review of all patients referred to plastic surgery via TRIPS during April 2020. Documentation standards were determined from national guidance. After introduction of a condensed guide, a second review was performed four months later. Results In April, 131 referrals were recorded on TRIPS. Only 22.9% of records met the standard. The most common omission was treatment advice. Following introduction of guidance, 215 TRIPS records were reviewed. The quality of clinical documentation improved in all aspects with a compliance rate of 89%. Conclusions Although TRIPS remains a useful tool for triage, it is a clinical document and must meet the standards of clinical record keeping. Introduction of clear guidelines improves overall compliance.

Yesterday, Today, and Tomorrow

2020 ◽  
pp. 160-176
Author(s):  
Vincent Malesela Mello ◽  
Mpho Ngoepe
Keyword(s):  
South African ◽  
Electronic Record ◽  
Legal Framework ◽  
Electronic Records ◽  
Records Management ◽  
Electronic Systems ◽  
Data Loss ◽  
Record Keeping ◽  
The Future ◽  
Electronic Records Management

Rand Water was one of the earliest institutions to introduce electronic records management in 1991. Over the period of three decades, there have been numerous changes at the institution, and within the South African legal framework, there is a need to transfer the digital records into archival custody. However, there is no infrastructure to ingest digital records into archival custody. This poses challenges to institutions such as Rand Water as they are forced to create an interim solution for electronic records preservation. The challenge is compounded by the fact that since implementing electronic systems, Rand Water has migrated to several products. There is a danger that some records might have been lost during migration. This chapter narrates on the electronic record-keeping within Rand Water from yesteryear to today in order to map the way for the future. It has established that Rand Water has implemented several ECMs and migrated to different products over the years. A further study on data loss and recoverability during migration to the different ECMs is recommended.

Clinical Record Keeping

2013 ◽  
pp. 139-150
Author(s):  
Mary Alice Fisher
Keyword(s):  
Risk Management ◽  
Patient Information ◽  
Ethical Issues ◽  
Legal Issues ◽  
Clinical Record ◽  
Patient Centered ◽  
Record Keeping ◽  
Clinical Patient ◽  
Ethical And Legal Issues

Chapter 10 discusses only ethical issues related to the confidentiality of patient information that has been recorded, whether on paper or electronically. It examines the shift away from clinical (patient-centered) and ethical (patient-protective) considerations and toward a risk management (therapist-protective) focus, and that documentation serves many functions, but addresses only ethical and legal issues related to confidentiality, regardless of the function being served.

Scottish Intercollegiate Guidelines Network (SIGN) guidelines on tonsillectomy: a three cycle audit of clinical record keeping and adherence to national guidelines

2002 ◽  
Vol 116 (6) ◽  
pp. 453-454 ◽  
Author(s):  
Alun Williams ◽  
Patrick Lee ◽  
Alastair Kerr
Keyword(s):  
Sore Throat ◽  
Clinical Record ◽  
National Guidelines ◽  
Record Keeping ◽  
The Third ◽  
Progressive Improvement ◽  
Clinical Records ◽  
The Impact

Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the indication for tonsillectomy in the management of sore throat were published in January 1999. To determine adherence to these guidelines in our unit, clinical records were examined on admission for tonsillectomy. Three cohorts were analysed. The first listed prior to SIGN, the second after SIGN and the third after presentation of the results of cohorts 1 and 2. The records were examined for documentation of the number of attacks of tonsillitis in the preceding year. The first cohort revealed poor documentation of attacks of tonsillitis (30 per cent). Thesubsequent cohorts showed progressive improvement in record keeping (74 per cent and 96 per cent). The adherence to SIGN guidelines for those with adequate documentation also improved (75 per cent, 80 per cent, 93.5 per cent). The importance of adequate record keeping to enable audit of practice and the impact of national guidelines on practice are discussed.

“Justice delayed is justice denied”

2015 ◽  
Vol 25 (3) ◽  
pp. 288-305 ◽  
Author(s):  
Mpho Ngoepe ◽  
Salmon Makhubela
Keyword(s):  
South Africa ◽  
South African ◽  
Justice System ◽  
Records Management ◽  
The South ◽  
Criminal Cases ◽  
Content Type ◽  
Record Keeping ◽  
The Media ◽  
African Media

Purpose – The purpose of this study is to investigate the cases of “delayed and denied” justice that resulted from a lack of or poor record-keeping in the South African courts and police service with a view to encouraging proper records management. Proper records management plays a significant role in supporting the justice system. Records provide the critical evidence that a particular action or transaction took place and can be used as evidence in a court of law. Without reliable and authentic records, government cannot administer justice and, as a result, offenders can be set free while the victims are denied justice. Design/methodology/approach – Utilising content analysis, this study extracted print media articles (2000-2012) relating to the “records and justice system” from the South African Media database, which is one of the databases hosted by the South African Bibliographic and Information Network. The study selected cases reported in the media to conduct follow-up interviews with a policeman, lawyer and judge to discover the implications of the unavailability of required records in court cases. Furthermore, access was given to three selected cases that were given high profile in the media and these cases were analysed to find out what the final verdict in each case was. Findings – Results of the study suggest that some criminal cases were withdrawn due to missing dockets or cases not properly registered. In some instances, records were reconstructed, resulting in the travesty of justice. The study concludes by arguing that if records are not accounted for, lawyers, prosecutors and magistrates could dispute the authenticity of records. As a result, justice for victims would be delayed and ultimately denied while the perpetrators are freed. Research limitations/implications – The findings and recommendations of this study may go a long way in helping courts in South Africa to manage records properly to support the justice system. Furthermore, the study is a useful compilation of the importance of missing records for social purposes. Originality/value – In an attempt to show the role of records management in the administration of justice in South Africa, this study used a triangulation of data collection tools. This is a new attempt, especially in the South African context. Previous studies in southern Africa only looked at the management of records in supporting justice system.

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