Australian clinical review / Australian Medical Association [and] the Australian Council on Hospital Standards
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To determine criteria for Accident and Emergency outpatient documentation, to review current practice and to overcome identified deficiencies. ⋯ The overall standard of outpatient documentation was high. Problem areas included the recording of cause of injury, significant laboratory and radiological findings, discharge instructions and time of disposal. Forms design was criticised by some users. Overall, however, non-compliance was seen to be less of a problem than lack of awareness by staff of what is important to document in an outpatient setting.