Iwan Dowie discusses the need for appropriate record keeping in community nursing. Through a series of legal examples, a case is made for good documentation, with suggestions that include factual, eligible and well-written records.

BACKGROUND: Optimal record keeping is a very essential component in health care provision especially in the surgical setting. This study aimed to evaluate the quality of surgical records in wards of a surgical department at Alexandria Main University Hospital, Egypt.
METHODS: We created a systematically designed checklist using standard hospital protocol and universal guidelines presented in the previously validated STAR and CRABEL auditing tools as a basis for Yes/No questions. This checklist was then used to prospectively evaluate the quality of surgical records of patients who underwent surgery in the surgical oncology department from July 2023 to October 2023. Total STAR and section-specific STAR scores were then calculated and compared statistically.
RESULTS: A total of 80 records were randomly selected and evaluated using the STAR questionnaire. All domains showed improvement compared to the baseline except for the discharge summary which did not change from an already relatively high baseline of 96±0.0. The highest improvements were observed in the anesthetic record and operative record domains which increased from 90.65±4.3 and 86.15±5.347 to 100±0.0 and 95.6±3.365, respectively.
CONCLUSIONS: Our study demonstrates that significant improvements in the quality of surgical records can be achieved by simply using preprepared templates, personnel education, and systematic auditing.

BACKGROUND: An audit was conducted in the exodontia department of Punjab Dental Hospital, Lahore, to assess the quality of records being kept by the undergraduate students in their third and final year, who form a major chunk of the workforce in the hospital, working in the mentioned department. The main objective behind this exercise was to improve the standards of record keeping and bring them in line with the standards practiced around the world, ultimately resulting in better patient care.
METHODS: This audit was undertaken while keeping in view all the necessary steps of a successful clinical audit. Initially, 150 records were randomly obtained from undergraduates of both third and fourth years and evaluated against a modified CRABEL score, which grades the records on a scale of 100. The results of this part of the audit were shared with the batches that were doing their clinical rotation in exodontia at the time of this audit, and a teaching session was conducted on better record-keeping standards. Following this, a repetition of the previous audit was undertaken to complete the audit cycle.  Results: The most commonly omitted component in the records in the initial audit was the patient complaint closely, followed by proper medical history and supervisor signatures. In the following, \'reaudit\' compliance was seen to be improved, and all the components of record-keeping less commonly being omitted except medical history and date.
CONCLUSIONS: A more comprehensive patient record keeping is possible with proper intervention and inculcation of record-keeping awareness in the undergraduate course, especially in the clinical years.

The use of WhatsApp in health care has increased, especially since the COVID-19 pandemic, but there is a need to safeguard electronic patient information when incorporating it into a medical record, be it electronic or paper based. The aim of this study was to review the literature on how clinicians who use WhatsApp in clinical practice keep medical records of the content of WhatsApp messages and how they store WhatsApp messages and/or attachments. A scoping review of nine databases sought evidence of record keeping or data storage related to use of WhatsApp in clinical practice up to 31 December 2020. Sixteen of 346 papers met study criteria. Most clinicians were aware that they must comply with statutory reporting requirements in keeping medical records of all electronic communications. However, this study showed a general lack of awareness or concern about flaunting existing privacy and security legislation. No clear mechanisms for record keeping or data storage of WhatsApp content were provided. In the absence of clear guidelines, problematic practices and workarounds have been created, increasing legal, regulatory and ethical concerns. There is a need to raise awareness of the problems clinicians face in meeting these obligations and to urgently provide viable guidance.

The United States is one of the largest catfish producers in the world. Louisiana is the leading producer of wild-caught catfish. Historically, the U.S. Food and Drug Administration inspected all seafood products; however, in 2008, Congress moved the inspection of fish in the order Siluriformes to the U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. Full enforcement of the rule began on 1 September 2017. The present study was conducted to assess the impact of USDA Siluriformes fish regulation on small Louisiana wild-caught catfish processors and to determine the microbiological quality of and Salmonella prevalence in raw fillets. Nine facilities participated in the assessment study. Surveys were conducted before and after full enforcement to identify whether facilities had established prerequisite programs and record keeping associated with sanitation, hazard analysis and critical control point (HACCP) plans, food defense, and product recall. The processors\' attitude about the change in regulations also was analyzed. For analysis of the microbiological quality and Salmonella prevalence, catfish samples were collected once per month for 2 years. Samples were evaluated for aerobic bacteria counts (APC), coliforms, Escherichia coli, Staphylococcus aureus, and Salmonella. The preenforcement survey revealed that only one facility had developed a HACCP plan, but it was not implemented. After 1 year of full enforcement, all the facilities developed and implemented a HACCP plan to process fresh catfish, and 78% of the processors reported a reduction in the amount of catfish processed due to limits in hours of operation and loss of fishermen. For microbiological quality, the mean (±SD) APC and counts of E. coli, coliforms, and S. aureus were 5.01 ± 0.70, 0.58 ± 0.89, 2.16 ± 0.77, and 0.73 ± 1.02 log CFU/g, respectively; 5.3% of the samples was confirmed positive for Salmonella. These findings indicate that after USDA enforcement, facilities improved food safety program documentation; however, the processing practices did not change. The microbial quality of the catfish fillets was within the acceptable levels in accordance with the International Commission on Microbiological Specifications for Foods.

Forensic odontology is the application of dentistry within the criminal justice system. Forensic expertise, including dental identification, mostly relies on dental records. We explored the practice of maintaining dental records among Croatian dentists, as well as their knowledge of legal regulations and the application of dental records in forensic odontology. In all, 145 dentists participated in an online survey. Questions covered general information on dentists, maintenance of dental records, and knowledge of legal requirements and forensic odontology. Overall, 70% of dentists obtain and archive written informed consents, while 87% record dental status. Generally, non-carious dental lesions and developmental dental anomalies were not recorded. About 72% of dentists record filling material and surfaces. Only 32% of dentists know the legal requirements for keeping records, whereas 21% have no knowledge of forensic odontology and its purpose. The survey revealed different practices in the maintenance of dental records, including significant flaws and lack of awareness of its forensic importance. This obvious need for additional education on proper maintenance of dental records could be met by including forensic odontology in compulsory undergraduate courses and postgraduate dental education. Establishing national and international standards in dental charting would comply with contemporary trends in health care and the requirements of forensic expertise.

This document is designed to provide a framework for assisted reproductive technology (ART) programs that meet or exceed the requirements suggested by the Centers for Disease Control and Prevention for certification of ART laboratories. This document replaces the document \"Revised Minimum Standards for Practices Offering Assisted Reproductive Technologies: A Committee Opinion\" published in 2019.

Continuity of midwifery carer improves outcomes, but there is significant variation in how such schemes are implemented and evaluated cross-culturally. The Angus home birth scheme in Scotland incorporates continuity of carer throughout pregnancy, labor, birth, and the postnatal period.
Manual maternity case note review to evaluate the 80% continuity of carer and 3% planned home birth rate targets.
Of 1466 women booking for maternity care, 69 joined the scheme. Forty-four had a planned home birth (3% overall), of whom seven were originally deemed ineligible. Of the 44, eight (18%) also achieved 80% continuity of carer with the primary midwife; by including a home birth team colleague, the continuity rate rose to 73%. Women whose care achieved home birth and continuity targets had lower deprivation scores. Eligibility issues, women\'s changing circumstances, and data recording lapses were complicating issues.
Targets must be both feasible and meaningful and should be complemented by assessing a broad range of outcomes while viewing the scheme holistically. By expanding eligibility criteria, the home birth rate target was met; including input from a home birth team colleague in the calculation meant the continuity target was nearly met. With dedicated and competent staff, adequate resource and political support, and when considered in the round, the scheme\'s viability within local services was confirmed. Other generalizable learning points included the need to standardize definitions and data recording methods. Comparability across schemes helps grow the evidence base so that the links between processes and outcomes can be identified.

OBJECTIVE: To evaluate whether implementing the Modified Early Warning Scoring system impacts nurses\' free text notes related to Airway, Breathing, Circulation and Pain in general ward medical and surgical patients.
BACKGROUND: The quality of nursing documentation in patient health records is important to secure patient safety, but faces multiple challenges whether being paper-based or electronic. Nurses\' ability to draw a complete picture of the patient situation is thereby compromised. Structured use of the Modified Early Warning Score, found to reduce unexpected death, might affect nurses\' free text documentation of clinical observations.
METHODS: A prospective, pre- and postinterventional, nonrandomised study adhering to the EQUATOR guideline TREND.
METHODS: Data on nurses\' free text notes were obtained in 1,497 patient records during one preinterventional (March-June 2009) and two postinterventional study periods (September-December 2010 and March-June 2011) in a Danish university hospital. Data were organised by the Airway, Breathing and Circulation principles and by nurses\' working shifts in the 56 hr surrounding the first recording of deviating vital parameters or a Modified Early Warning Score ≥ 2. Preinterventional free text notes were compared with notes from the two postinterventional periods, respectively.
RESULTS: In the 8-hr working shift where deviations in vital parameters were recorded for the first time, nurses\' free text notes related to patients\' breathing (B) increased significantly, comparing 2009 with 2010 and 2011, respectively. In the 24 hr following initial deviations in vital parameters, a significant increase in free text notes was identified concerning Airway, Breathing and Circulation-related symptoms or problems.
CONCLUSIONS: Mandatory use of the Modified Early Warning Score and related implementation activities significantly impacts nursing documentation of free text notes.
CONCLUSIONS: Nurses\' practice of communicating observed clinical symptoms by documenting free text notes should be supported through measures to enhance situation awareness.

UNASSIGNED: clinical audits highlight areas where care may not be of the desired quality; they are essential to ensure care is safe and effective. Effective assessment and management of pain have been shown to improve patient wellbeing and clinical outcomes.
UNASSIGNED: this audit aimed to identify compliance with pain assessment tools and documentation within intensive care and make recommendations to improve practice.
UNASSIGNED: compliance with documenting pain assessments was poor, a finding that is consistent with the literature. Although a wealth of evidence has shown pain assessments are not being completed effectively, this continues to be a problem. Intensive care has significant areas for improvement in this area, which would improve patients\' experiences and outcomes. Nurses should be educated in the use of pain assessment tools and compliance.
UNASSIGNED: providing patients in intensive care with appropriate analgesia benefits their physical and psychological health. Areas for improvement identified in this audit include that pain assessments need to be carried out and documented regularly. The audit has implications for practice in that it shows a need for reinforced education for staff, better communication and updates to promote pain assessment and the implementation of guidelines.