• MANAGEMENT OF E-CLINICAL CHART AUDIT

    MANAGEMENT OF E-CLINICAL CHART AUDIT

    NURSING
  • CRITERIA OF COMPLIANCE 

    The criteria and elements for compliance scoring during the assessment and audit for quality content of patient medical records as below: - 

    • Assessment and Continue Care at Ward       (100%)
    • Assessment and Continue Care at OT          (100%) 
    • Medication Administration Records               (100%)
  • E-CLINICAL CHART AUDIT

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  • NURSING

  • MSQH Clause: 4.2.1.4 
    The assessment, planning, implementation and evaluation of nursing care is the responsibility and accountability of each and every registered nurse

    MSQH Clause: 4.3.1.8
    The Nursing Services have an established initial assessment process for patients where their nursing needs are identified and followed by regular reassessment as deemed necessary. Nursing assessment done and completed within 24 hours of admission. 

    MSQH Clause: 6.1.10.2 (2)
    Evidence of continuity of care in medical records, including history taking, physical examination, investigations, appropriate treatment given, etc.

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