Medical documentation in emergency department Research Article

Document Type : Original Article

Authors

1 Health Administration Specialist

2 Dental Assistant

3 Epidemiologist

4 Nutrition Technician Saudi Ministry of Health, Kingdom of Saudi Arabia

Abstract

Abstract:





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 Improving Emergency Department Documentation for Enhanced Patient Care. Background:
Accurate and efficient documentation is crucial in the emergency department (ED) for optimal patient care, communication, and legal protection. However, capturing details promptly can be challenging, particularly during critical scenarios. This research investigates the importance, components, and potential improvements of ED medical documentation. Objectives:Define medical documentation in the ED context.Identify the main components of an ED medical documentation report.Explain the significance of proper documentation in the ED.Explore methods to enhance documentation quality and efficiency.Methods:This descriptive analytical study utilizes questionnaires to gather data from healthcare professionals. Statistical analysis using SPSS will be employed to analyze questionnaire responses.Expected Findings:
The research aims to demonstrate:The crucial role of comprehensive and timely ED documentation.The essential components of an effective ED medical record.The potential benefits of implementing strategies like templates, education, dictation, and electronic record optimization for improved documentation quality.Implications:This study aims to contribute to improved ED documentation practices, leading to:Enhanced patient care through accurate information availability and better decision-making.Efficient communication among healthcare professionals.Reduced risk of medical errors and malpractice. Improved healthcare system performance through data analysis and quality assurance.
 

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