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In March 2019 the Pacific Association of Pediatric Surgeons held its annual conference in Christchurch, New Zealand, a normally peaceful city that was in the process of rebuilding following the devastating earthquakes of 2010 and 2011. Then the day after the conference concluded a horrendous atrocity was committed in two nearby mosques which presented the hospital with 25 years of major gunshot injuries in just one hour. The remarkable response of the hospital and its staff, the victims and the broader community are outlined. Although the surgical response was impressive, lessons could still be learnt. These related to the consequences of the lack of warning as the ED was flooded with casualties, the effects of scoop and run when a disaster occurs near a hospital, limitations around record keeping, the rapid arrival of expert support into ED, pre-empting pressure points, designation of two key destinations and avoiding patient return to ED after imaging, the importance of flexibility and collaboration between services, the consequences on normal hospital activity in the weeks following the incident and the behaviour of victims. The response of PAPS to the event was no less impressive: consistent with its longstanding commitment to the care and welfare of children around the globe, our organisation, donated over $40,000 through the Christchurch Foundation towards scholarships for the children of the victims to support their higher education. Out of tragedy can emerge the finest human qualities.

Background of the Study: This paper present the functional requirement in Archive Records Management System (ARMS) that provide a comprehensive record keeping management system based on the organization function according to the business activities and process. Purpose: The purpose of this article is to describe the core functional requirement for record keeping system to support users in performing their task that related to electronic record management system. Method: The method used in this article are based on the previous research, guidelines and standards. Findings: Furthermore, this article similarly aim to evaluate and identify the core functional requirement of archive records management system based on the standards use. This article intent to make user aware towards the core functional requirement in managing electronic records system to fulfil the needs and meet based on proper requirements. Subsequently, through completion this article, the research limitation and difficulties in this study is there are too many requirement of electronic record keeping system available that make users are confused to differentiate between requirements. Meanwhile, the user does not know to choose the right requirement that meet organization function and activities. Other than that, it is quite hard to keep core functional requirement sustain in line with the compliance in organization. Conclusion: The originality this article is to provide a clear content and original requirement based on Archive Records Management System implementation for record professional to recognize the high levels of competencies as well as effectiveness reflection in handling Archive Record Management System (ARMS).

Background This quality improvement project was based at The Royal Bolton Hospital across our four Complex Care wards. Introduction We have recently transferred to electronic record keeping. At these points of transition there may be an adverse impact on the quality of patient care and safety. We recognised on our own ward there were inaccuracies between the required paper form and electronic documentation of DNACPR decisions. Consequently, we wanted to review and improve the accuracy of our DNACPR documentation to ensure safe and effective patient care. Methods To gauge the scope of the problem we audited 87 patient’s electronic and paper notes, with no exclusion criteria. We reviewed whether each patient had a formal resuscitation decision, and if a DNACPR decision had been made whether we met our hospital policy by having: 93% of the 87 patient’s had an active decision regarding resuscitation, with a DNACPR decision documented for 50 patients. Of these 50 patients only 11 had all three forms of documentation. More worryingly, there were discrepancies in the documented DNACPR decisions for 11 patients across paper and electronic records. Interventions We escalated our concerns to the Clinical Governance team who sent out a trust wide SBAR highlighting this as an urgent clinical issue. On a directorate level we incorporated DNACPR decision documentation into our afternoon safety huddle and arranged informal teaching for medical, nursing and administrative staff. Results Reassuringly, the subsequent re-audit of 90 patient’s notes showed only one patient to have a discrepancy between paper and electronic documentation. We saw an improvement to 98% having paper forms in the right bedside notes and 100% having a documented electronic DNACPR decision. Conclusion Through local education and trust-wide dissemination of our expected standards we have seen some improvement. We recognise the importance of maintaining this, and importantly that there is still work to be done. The electronic “Resuscitation and treatment escalation plan” is still rarely completed and provides important information on escalation of care and thus will be the focus of a further educational intervention.

Contemporaneous and thorough record keepingfor conscious sedation in dentistry is goodclinical practice; it is necessary to ensure patientsafety and helps protect patients and clinicians(medicolegally). Clinicians providing a sedationservice should be familiar with guidelines andtheir implementation. Record keeping forconscious sedation in dentistry is a useful audittopic in both primary and secondary care.

Background of the study: Electronic record keeping is one of the things that can significantly affect the implementation of e-government, because every transaction with the e-government will create electronic archives. However, many countries in the world still do not pay attention to the practice of managing their electronic archives, especially in developing countries, one of them is Indonesia. Purpose: This article aims to know the practice of electronic record keeping in the implementation of Indonesia e-government. Method: The writing method used in this article is a literature review by identifying secondary literary sources and archival legislation in Indonesia as a basis for conducting electronic record keeping. Findings: The implementation of electronic record keeping should be done well and correctly. Because when electronic record keeping in a government has been doing did good and true, it will automatically be able to support the implementation of e-government as already done by developed countries in the world. Conclusion : Electronic record keeping in developing countries is used as a strategy in implementing e-government.

This second edition guideline was prepared to assist in the planning, conduct and interpretation of studies to assess the efficacy of parasiticides against ectoparasites of ruminants. It provides updated information on the selection of animals, dosage determination, dosage confirmation and field studies, record keeping and result interpretation. This guideline is intended to assist investigators on how to conduct specific studies, to provide specific information for registration authorities involved in the decision-making process, to assist in the approval and registration of new ectoparasiticides, and to facilitate the worldwide adoption of standard procedures.

Since 2018, there has been no requirement to bring decisions about the withdrawal of clinically-assisted nutrition and hydration (CANH) in patients with persistent disorders of consciousness before the courts, providing that the requirements of the Mental Capacity Act 2005 (MCA) are fulfilled. Subsequent British Medical Association and Royal College of Physicians guidance on CANH withdrawal recommended standards of record keeping and internal and external audit to ensure local decision making was compliant with the MCA to safeguard patients. The scope of the guidance also included patients with stroke and neurodegenerative disorders. Freedom of Information requests made 2 years after the introduction of this guidance have shown that none of the NHS trusts or clinical commissioning groups who responded were undertaking any systematic monitoring of these decisions. Neither is the Care Quality Commission reviewing these decisions, as there is ‘no statutory requirement’ to do so. It appears there is a lack of organised scrutiny of these highly complex life-ending treatment decisions. This omission must surely be a cause for concern.

This article reviews the key aspects of reducing the litigation aspects of the management of periodontal diseases and in particular periodontitis. Litigation arising from gingivitis, the other type of periodontal disease, is very rare and is therefore not considered in this article. This paper considers diagnosis, record keeping, communication, management of periodontitis including non-engaging patients and referrals. It provides guidance to reduce risks and improve the care for patients.

Technology plays a vital role in herpetoculture because ectothermic animals rely on their environment to carry out basic physiologic functions. Controlling the environment appropriately ensures the health and welfare of captive reptiles and amphibians. This article summarizes some of the technological advances and products currently available, including lighting, climate control, and recordkeeping.

There are some dento-legal mantras that have, by default, come to be understood as the truth, for example: “If it ain't in the notes, it didn't happen” and “Good records, good defence; poor records, poor defence; no records, no defence.” The opposite view was offered by the trial judge in a dental clinical negligence case in recent years. The judge's view can be summed up as: “If you don't make a note of something that has happened, you leave yourself at risk of proceedings like these.”

Aims and objectives: 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. Design: 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. Conclusion: Mandatory use of the Modified Early Warning Score and related implementation activities significantly impacts nursing documentation of free text notes. Relevance to clinical practice: Nurses’ practice of communicating observed clinical symptoms by documenting free text notes should be supported through measures to enhance situation awareness.

RATIONALE AND KEY POINTS Effective record-keeping and documentation is an essential element of all healthcare professionals' roles, including nurses, and can support the provision of safe, high-quality patient care. This article explains the importance of record-keeping and documentation in nursing and healthcare, and outlines the principles for maintaining clear and accurate patient records. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.

In Ethiopia, farmers are practicing animal husbandry under different production systems. However, the production and reproduction performance of dairy cows are very low due to the reasons such, the low genetic capacity of the indigenous cow for milk production, substandard feeding and poor health care. By considering this, the paper is aims to review the status of production, reproduction and management practices of indigenous and crossbred dairy cow. A number of research works have been done since two last decades to evaluate and improve the production and reproduction performance of indigenous and crossbred dairy cow in the country. On this basis, the average milk yield was not being exceeded 2liters per day for indigenous dairy cow. On the other hand, the average age at first service was ranged between 18.7 and 24 months for crossbred dairy cow. Further, the average age at first calving was being extended to 48.9 and 37.95 months for indigenous and crossbreed dairy cow, respectively. Regarding management practices, more farmers are using separate house for their dairy cow and they haven’t experience of record keeping in different parts of the country. Moreover, stall feeding was the primary feeding method which has been reported by many authors. Therefore, it should be emphasized to enhance improved management practices by the dairy farmers.

Introduction:we sought to explore the knowledge and practices among traditional bonesetters (TBSs) in the Northern Region of Ghana and to assess opportunities for their engagement with the formal health sector. Methods:we identified 28 TBSs widely distributed in the Northern Region. They were interviewed using qualitative and quantitative methods, regarding their background, training, current practices, opinions regarding orthodox care, and interests in future linkages with the formal health sector. Results:most TBSs (67.9%) had no formal education and most (85.7%) learned their skills from older family members. Their treatments included reasonable versions of closed reduction and immobilization, but also use of locally-derived concoctions and spiritual aspects, such as incantations. Only 21.4% regularly referred complications to hospital. Nonetheless, all endorsed advantages to orthodox care, such as X-rays (100%), record keeping (100%), and pain management (85.7%). Almost all (96.4%) expressed an interest in training courses or other engagement with the formal health sector. Topics in which they were interested for training included record keeping (100%), pain management (85.7%), and management of open fractures and complications (82.1%). Conclusion:factors making linkage between TBSs and the formal health sector difficult included low levels of formal education, training through secretive in-family methods, and spiritual and mystical aspects of their practice that might make communications about modern medicine difficult. Nonetheless, most indicated interest in linking with modern care, especially through training courses. Topics they suggested for such courses provide a foundation to build on in future efforts to engage TBSs with the formal health sector.

Dr. Louise Eisenhardt was one of the first neuropathologists and was responsible for the development of tumor diagnosis guidelines. This historical vignette reviews her previously unseen handwritten notes in which she describes methods used by her and Dr. Harvey Cushing to obtain patient follow-up data for their Brain Tumor Registry. Her description spans 50 years, using “every possible clue to be jumped upon in [their] clinical records and correspondence.” Their follow-up was divided into two periods: early follow-up (1912–1932) and registry (1933–1961). During early follow-up, patients were asked to write to them on the anniversary of their operation. The foundation of the registry necessitated the use of “considerable effort on [their] part to gather up old threads” including renewed contact with patients after 15–20 years. Methods of follow-up included continued verbal and written correspondence with patients and “strong-arm methods,” including use of the Fuller Brush man and the exhumation of a body. Drs. Eisenhardt and Cushing believed “every case was important in adding to our collective knowledge of various types of tumors particularly in relationship to life expectancies and suggesting improvement in surgical treatments.” Dr. Eisenhardt’s meticulous record keeping allows for insights into the first known outcomes-related tumor registry in neurosurgery.

E-KTP implementation in Gresik regency, until 2014, found various problems involved Double Data Recorded up to 23,765 inhabitants; Anomalies or substantial deviations of data elements as 69,230 inhabitants; only 20% children Birth Certificate were Recorded, issuance of Death Certificate was never implemented. The best alternative to solve this problem is to update the attribution of Family Card which encompasses most data element of the resident identities. Family card updating program named as Kakek Ku Datang (Kartu Keluarga Ku Data Ulang), an innovation program of Gresik. The purpose of this study is to analyze the implementation of Kakekku Datang to improve the ease of service and data validity in order to achieve single identity in Gresik. This study is observational through discussion forum to evaluate program innovation as a human-centred design. Population of the study is village register officials, sub-district officials, and resident and civil registry officials in Gresik. The results indicate that during the implementation from January 2015 - December 2017, Kakek Ku Datang has successfully achieved updating of 229.332 KK Count O; recording of birth certificates as 85%; recording of death certificates as 13.510 inhabitants; recovery of double & anomalies data as 46% (2017), and recording of e-KTP massively increased to 88.9%. Kakek Ku Datang potentially achieves single identity through the combination between inclusive service and technology in human-centred design.

Paracentesis, the aspiration of fluid from the abdominal cavity, is a diagnostic and therapeutic procedure frequently performed in gastroenterology wards. Paracentesis is generally a safe procedure but there are variations in practice and some potential complications such as bleeding and injury to

The study aims at estimating the effect of producers‘ socio-economic characteristics and the farm structure on the probability of becoming a member of an agricultural organization. For this aim Ordered Probit Model was applied. The data of 2010 production period was collected from 66 dairy cattle farms through questionnaires based on stratified random sampling method. While 74.2% of producers were not a member to any organization, the remaining 18.2 and 7.6% were members of one and more than one organizations, respectively. The result of study showed that the variables of experience, education level, milk yields, milking machine existence, and record keeping rate increased the probability of becoming a member to any agricultural organization. Government financial, technical and educational supports towards increasing the number of cattle farms, with high educated and experienced labor and high productivity levels, which are associated in an agricultural organization, could promote the willingness of producers in the region in participating of agricultural organizations as a member.

The importance of transparent, complete, authentic and timely information comprehensible for all the users of financial reporting has grown in the context of Ukraine’s integration in the international economy. The issue of harmonizing the national accounting system with the international standards is, therefore, on the agenda of the national statistics system. Apart from this, introduction of the international accounting standards in the Ukrainian statistics practice is expected to make Ukraine more attractive for foreign investors and lenders. As theoretical and practical problems related with harmonizing the national accounting standards with international ones are not fully elaborated, the article’s purpose is to analyze the methodology of fixed assets recording by international and national standards, with providing, in table form, comparative characteristics of the underlying sections of International Accounting Standards (IAS) 16 and Rules (Standards) of Accounting (R(S)A) enforced in Ukraine, and to illustrate their practical use. The comparison covers recognition, valuation, recording and reporting of fixed assets, elements of the original cost (estimates at the date of recognition), formation of the original value of fixed assets as a result of various events, revaluation of fixed assets, frequency of revaluation of the liquidation value of fixed assets etc. Practical issues related with fixed assets overvaluation (undervaluation), depreciating, disposal and exchange are highlighted. The comparative analysis shows quite significant differences between the two documents in valuation, revaluation, liquidation, disposal of fixed assets. They can be explained by national specifics of record keeping in Ukraine, fully considered in the national standards, and, consequently, by adaptation of accounting in Ukraine to the national economy needs.

Veterinary technicians are continuously evolving with changes in veterinary medicine specialties. Traditionally, ambulatory medicine has focused on large farm animal medicine. In today's world, technicians are finding themselves on house calls and in ambulatory practices that focus on exotic and zoologic species. In ambulatory medicine, technicians assist during field surgery work, onsite diagnostics, and in other various roles. The conditions often are not ideal and require attention to detail to avoid mistakes in record keeping, inventory, and unnecessary risk.

An NHS trust recently agreed a £45 000 settlement with the family of a woman who was given treatment contrary to her advance decision for some 2 years before she died. In this article, Richard Griffith discusses the requirements for a valid applicable advance decision to refuse treatment and a district nurse's duty to record and give effect to the wishes expressed within it.

Environmental enrichment in zoos and aquariums is often evaluated at two overlapping levels: published research and day-to-day institutional record keeping. Several authors have discussed ongoing challenges with small sample sizes in between-groups zoological research and have cautioned against the inappropriate use of inferential statistics (Shepherdson, , International Zoo Yearbook, 38, 118-124; Shepherdson, Lewis, Carlstead, Bauman, & Perrin, Applied Animal Behaviour Science, 147, 298-277; Swaisgood, , Applied Animal Behaviour Science, 102, 139-162; Swaisgood & Shepherdson, , Zoo Biology, 24, 499-518). Multi-institutional studies are the typically-prescribed solution, but these are expensive and difficult to carry out. Kuhar ( Zoo Biology, 25, 339-352) provided a reminder that inferential statistics are only necessary when one wishes to draw general conclusions at the population level. Because welfare is assessed at the level of the individual animal, we argue that evaluations of enrichment efficacy are often instances in which inferential statistics may be neither necessary nor appropriate. In recent years, there have been calls for the application of behavior-analytic techniques to zoo animal behavior management, including environmental enrichment (e.g., Bloomsmith, Marr, & Maple, , Applied Animal Behaviour Science, 102, 205-222; Tarou & Bashaw, , Applied Animal Behaviour Science, 102, 189-204). Single-subject (also called single-case, or small-n) designs provide a means of designing evaluations of enrichment efficacy based on an individual's behavior. We discuss how these designs might apply to research and practice goals at zoos and aquariums, contrast them with standard practices in the field, and give examples of how each could be successfully applied in a zoo or aquarium setting.

Buried Bumper Syndrome (BBS) is a rare complication of percutaneous endoscopic gastrostomy (PEG) tubes. Advice in prevention guidelines differ, but locally agreed protocols can be agreed using the existing evidence. Consideration needs to be given as to how tightly a PEG is clipped after insertion to prevent gastric leakage, and how long after the procedure should it be loosened to prevent BBS. The distance a PEG tube is advanced and whether it should be rotated is also important in order to prevent BBS. The locally developed protocols need to include clear instructions for staff and patients and a supportive education programme, alongside clear record keeping.

Hayvancılık işletmelerinde uzun süre saklanan veriler, hayvansal üretimlerde verimliliğin artırılabilmesi, hayvan damızlık değerlerinin ortaya konulabilmesi, nitelikli damızlık ihtiyaçlarının karşılanabilmesi, etkin ıslah organizasyonlarının yapılabilmesi, yüksek gelir elde edilebilmesi, sürüden ayıklanacak veya damızlık olarak elde tutulacak hayvanların belirlenmesinde etkin rol oynayacaktır. Hayvancılık işletmelerinde tutulan önemli teknik veriler arasında; damızlık koç/boğa/teke kayıtları ve bunlara ilişkin üreme, büyüme- gelişme, verim kayıtları (küçükbaş hayvanlarda yapağı ve kıl verimi, besideki canlı ağırlık artışları, yem tüketimi, laktasyon ve süt verimi), döl verimi ölçütleri, kesim ve karkas ölçü ve özellikleri, et kalitesine ilişkin kayıtlar, hayvan hastalıkları ile aşı uygulamaları ile ilgili kayıtlar gösterilebilir. Bu verilerden hayvana ait tanımlayıcı bilgilerin veritabanlarında saklanması ve hayvan takiplerinin yapılması gibi konularda Türkiye’nin AB’ne uyum programı çerçevesinde Tarım ve Orman Bakanlığı’nın 10.02.2009 tarihli 27137 sayılı resmi gazetede yayımlanan “Koyun ve keçi türü hayvanların tanımlanması, tescili ve izlenmesi yönetmeliği” kapsamında zorunlu hale getirilmeye çalışılmıştır. Günümüzde sağlıklı verilerin elde edilebilmesi ve eldeki verilerin de güvenle saklanabilmesi amacıyla MySQL, MS SQL, Postrage SQL, Oracle, Firebird, IBM DB2, MS Access gibi veri tabanı yazılımlarından yararlanılmaktadır. Bu veritabanı yazılımlarının ve Veritabanı Yönetim Sistemlerinin (VTYS) kullanımının ve işletmeye maliyetinin bilinmesi, işletme için önemlidir. Bu çalışma ile bu yazılımların işletmeye kattığı değer ve işletmeye maliyetleri konusunda bilgi vermek amaçlanmıştır. The data stored for a long time in livestock enterprises will play a crucial role in increasing the productivity in animal production, revealing animal breeding values, meeting qualified breeding needs, making effective breeding organizations, obtaining high income, determining the animals to be kept or as a breeder. Among the important technical data kept in livestock enterprises; ram, bull, and goat and their reproduction, growth-development, yield records (animal weight and wool yield in small ruminants, body weight gain, feed consumption, lactation and milk yield), reproductive performance measures, slaughter and carcass dimensions and characteristics records such as meat quality, animal diseases and vaccination practices can be shown as important technical data in livestock enterprises. Issues such as followed animals and storing identifying information of the animals from this data in the database are being made compulsory for conformity program of Turkey with the European Union by the rule number 27137 “Regulation on the identification, registration and monitoring of sheep and goat type of animals” that published in the official newspaper by Agriculture and Forestry Ministry on 10.02.2009. Nowadays, database software such as MySQL, MS SQL, Postrage SQL, Oracle, Firebird, IBM DB2 and MS Access are used in order to obtain healthy data and store the data safely. Knowledge of the use and cost of this database software and Database Management Systems (DBMS) is important for the enterprise. In this study, it is aimed to give information about the software that adds value to the enterprise and their costs of the operations on enterprise.

Background/ Aims: Standardised numeric grading scales are used in ophthalmic practice to improve consistency between clinicians in recording the severity of ocular conditions and to facilitate the monitoring of such changes. We investigated the intra- and inter-observer grading reliability and the agreement between subjective Cornea and Contact Lens Research Unit (CCLRU) and Efron grading scales as well as a new Advanced Ophthalmic Systems (AOS) software which uses an objective approach to grading conjunctival hyperaemia.Methods: One experienced observer graded n = 30 bulbar and n = 26 palpebral conjunctival hyperaemia images to 0.1 increments. Masked grading of randomised images was undertaken for all three methods, on two separate occasions. The agreement within and between the grading methods was assessed between sessions, and compared to the results of a novice observer.Results: There were no statistically significant differences (P > 0.05) between test and retest values. However, repeatability in the grading estimates of both bulbar and palpebral conjunctival hyperaemia was improved using the AOS grading method (R2 = 0.998; Coefficient of Repeatability CoR 0.10–0.13), compared to Efron (R2 = 0.926; CoR 0.62) and CCLRU (R2 = 0.885–0.911; CoR 0.50–0.78). Intraclass coefficient correlations (ICC) improved inter-observer agreement using objective (> 0.995) versus subjective methods (0.853–0.959).Conclusion: These subjective and objective grading methods are not interchangeable. Due to the excellent repeatability and improved agreement between experienced and novice observers, the objective grading method provides a more consistent approach when grading ocular abnormalities and may achieve greater reliability in record keeping and clinical monitoring in the future.

Introduction: In Japan, the PMDA conducted inspections based on GCP in the review process of the submission of NDAs or sNDAs. In this descriptive study, we examined in detail the contents of exclusion data from submitted clinical data package subjects in the results of GCP inspections in Japan for NDAs or sNDAs. Methods: For NDAs or sNDAs approved in Japan between January 2007 and December 2017, we gathered information about the PMDA's conclusion from review reports, concerning the results of the GCP on-site inspection. Results: For 1193 NDAs and sNDAs approved in Japan between 2007 and 2017, there were 37 cases in 33 applications of non-compliance with GCP, including 1 by the sponsor and 32 at the clinical trial site. Of the 32 applications at the clinical trial site, 9 cases were categorized as “General findings” and 28 as “Findings for individual subjects.” Of the 9 “General findings” cases, problems related to the IRB were most common (44.4%), while faulty record keeping was the most common (60.7%, 95% confidence interval 42.6%–78.9%) problem in the 27 “Findings for individual subjects” cases. Violations of GCP were mostly found in 2007 and 2009, but few were found after 2013. Conclusion: In this study, we revealed that record keeping was the most common reason for exclusion from the analysis data of subjects in the results of GCP inspections. It is necessary to be careful in maintaining medical records, especially when conducting clinical trials without using electronic medical records. Keywords: GCP, Clinical trial, GCP inspection, GCP violation

Almost half of private primary care services and slimming clinics in England aren’t providing safe care, the country’s healthcare regulator has warned. For its new report the Care Quality Commission analysed a sample of inspection reports of private primary medical care services, including general practice services and specialist clinics.1 Safety was identified as the biggest problem across the private primary care sector. In particular it noted concerns about the safety and efficacy of prescribing, poor record keeping, and clinicians not communicating their activity with the patient’s GP. This was often related to …

In 1947, the Gold Coast Police Band embarked on a four-month long tour of Great Britain. The event, which was organized by the Accra government and Colonial Office in London, was designed to be a carefully-scripted showcase of the Empire’s merits and future prospects. As a result, the bulk of the written records that colonial officials compiled about it focused not on its actual progression or outcomes, but on their own preparations and confidence about its “inevitable” success. This article examines this pattern of colonial record keeping and looks beyond its overt declarations to analyze a series of incomplete exchanges, isolated letters, and brief references that tell a much more complicated story. Insisting that these archival fragments reveal that the tour did not go as planned, it also proposes that we can use them to engage two topics important to studies of African music during the colonial period: the state’s strategic use of music and the colonial archive’s utility as a source of information about past musical events.

The history of archives is very old. Thousands of clay tablets dating into to the third and second millennium B.C were found in cities such as Elba, Syria (2350 B.C.). These archives have been fundamental for understanding ancient alphabets, languages, culture, political and social structure prevailing in those time. Archives were established by the Church from the fifth century and are kept till nowadays. People started to register and record their activity and events, in the rocks, animal bones and skin. Archives play an important role in the nation memory. Archives and records are important for organizations, individuals and the community. They give and provide us an evidence and information about past events and actions. Record keeping has a long history in different civilization, and archives transfer to us the evaluation of the human mind and the understanding of different events during the history, like the collapse of civilization, boundaries dispute, wars that decimated the humans... Archives collect original unpublished material or primary sources; these records are unique and irreparable. If an archival record is damaged, stolen or exposed to various dangers such as wars and terrorist attacks, the information it contains is lost forever. Archives can be an incredibly rich holder of information that should be kept according to legislation and regulations in favour of the archive staff or its clients and should enable the scientific, legal and public use of preserved archival records. This paper will describe in brief these uses and reflect to National Records and Archives Authority in Oman as example.

Residents living in a care home are likely to have a number of long-term conditions for which they may be taking multiple medicines. Alison While offers some valuable advice for staff in relation to the importance of good staff training and record keeping

The article is devoted to the study of blockchain technology in the financial sphere of Ukraine, as well as accounting and audit of their application in domestic and international practice. The article contains data on the prospects of blockchain development in the world and in Ukraine, as well as information on the peculiarities of the use of such technologies in the perspective areas – accounting and audit. The article argues that the development of blockchain technology will enable the transition to more modern methods and techniques, which in turn will allow to modernize the accounting and auditing system. The principle of triple entry as a major component of blockchain technology in accounting is emphasized. One of the most promising areas of application of blockchain is accounting for accounts payable and receivable, tax accrual and payment, record keeping and documentation. The article highlights the advantages and disadvantages of using blockchain technology in the financial sphere of Ukraine.

Health professionals are no stranger to paperwork. In this article Angela Smith and Julia Parkhouse explore how and when care providers could end up in court as a result of poor record keeping, and the ways in which they could be held accountable

Beef cattle producers engaged in the Alabama Beef Cattle Improvement Association (BCIA) Commercial Record Keeping Program were surveyed to assess application of record keeping to operational management. In 2014, the specialized record-keeping system utilized by Alabama BCIA transitioned from software-based, centralized processing to an internet-based system to allow for hands-on use. The application of this new system and hands-on use was evaluated. A brief, online survey of 14 multiple-choice questions was developed. Question topics included basic demographics, value level, length of use, frequency of use, devices used, record areas, management decisions and meeting needs. The Qualtrics®XM web-based survey tool was used to evaluate results. A response rate of 44.64% was reached. Respondents represented cattlemen in business for 30+ years 44%, 20+ years 32%, 10+ years 12%, 5 to 10 years 4%, 3 to 5 years 4% and less than 3 years 4%. Cow inventory reflected 50 to 100 cows 24%, 100 to 200 cows 24%, 20 to 50 cows 20%, 200 to 300 cows 16%, 300 to 400 cows 8% and 500+ cows 8%. Longevity of BCIA record keeping reached 20 to 30 years 24%, 1 to 5 years 24%, 5 to 10 years 20%, 10 to 15 years 16%, 15 to 20 years 12% and beginning 4%. Value of performance records rated extremely valuable 72.0%, and hands-on access rated very valuable 92.0%. A majority indicated accessing the system weekly 40.0%, monthly 16.0% or daily 8.0%. The most common device was combination of computer and smartphone 36.0%. The most active record keeping areas were calving records 21.57%, weaning data 19.64% and culling cows based on performance 17.86%. Planned expansion was yearling data for replacement heifers 22.58% and collecting mature cow weights at calf weaning 20.97%. Overall, responding cattle producers indicated the internet-based system was definitely meeting their needs 88.0%.

A former doctor who ran two US contract research companies has been imprisoned for 28 years for faking the results of clinical trials and in many cases failing to even administer the drugs under study. Sami Anwar of Richland, Washington State, owned companies that operated trial centres for studies into the treatment of cholesterol, diabetes, heart disease, liver fibrosis and cirrhosis, opioid addiction, rheumatoid arthritis, asthma, and bipolar disorder, among other conditions. Former clinic staff testified that the trial drugs were usually thrown away and fake data entered. When subjects were given the drugs, the record keeping was largely fraudulent and useless, the court heard. …

Introduction: Details mentioned in Bed head ticket (BHT) and investigations are taken into consideration when an opinion is made with regards to the medico legally significant trauma. Shortfalls of documents can lead to misdiagnosis or wrongful diagnosis. This study was conducted to find out the adequacy of records on BHTs and availability of investigations on patients who had been admitted following trauma with medico legal significance. Methods: A prospective descriptive study was carried out on patents who were admitted following medico-legally significant trauma during a period of one year, from Aug 2017 to Aug 2018 by perusing their records. The adequacy of the documentation was assessed according to a pre-prepared scale. Results: Analysis of on admission historical and preliminary details revealed that out of 1102 records, only 26% (n=286) had mentioned the time duration since the incident. Recorded cardiovascular stability on admission was above 86% (n=950) though level of consciousness was not mentioned by 19% (n=211). Nature of the injuries were correctly recorded by 65% (n=720) while the location of them were correctly recorded only by 29% (n=316). Surgical procedures were adequately mentioned only among 39% (n=425). Conclusions: The study revealed that there are gross inadequacies with regard to the records on BHTs made by the doctors. This can lead to limitations in addressing medico-legal issues and sometimes can result in wrong opinions leading to injustice. Need for continuous professional training with special attention to record keeping is highlighted. Further, the quality of records can be further improved with regular audits, continuous professional developmental activities and introducing a common format for documentation in admission, surgical procedures and investigations.

A GP who was suspended for nine months from the UK medical register for failings in record keeping and delayed referral of seven patients may resume practice with conditions, a tribunal has ruled, despite the fact that he still refuses to accept many of the factual findings against him. Kevin Newley, who qualified at the University of Leicester in 1982, was suspended last year by a medical practitioners tribunal after a hearing that spanned nearly two years with several adjournments.1 He was found to have failed to recommend a digital rectal examination in older male patients on 15 occasions when it was indicated. Several …

NHS Resolution manages the Clinical Negligence Scheme for Trusts, and aims to reduce the cost of litigation in terms of clinical negligence claims. To achieve this, potential clinical negligence claims are screened to assess whether to defend the claim or to provide an out-of-court settlement. Nurse experts from all nursing specialties are engaged to review all documentation and patient records to offer an opinion on the viability of a claim. This article describes the processes involved in assessing tissue viability clinical negligence claims, providing examples of evidence that guided decisions and advice on how nurses can protect their organisation from costly litigation.

Many public secondary schools in Nigeria seemly do not have a well-coordinated and effective counselling programme for their learners. Most often the principal appoints any cool-headed or pious teacher to be in charge of the counselling department without proper and adequate training. The teacher assumes this dual responsibility without specific job description. For effective counselling in the best interest of Nigerian learners, a role description for school counsellor within counselling theoretical framework based on American school based policies; be it clinical, eclectic, or client-centre is direly needed in Nigeria. This study addresses the need of school-based policies to enable effective counselling programmes that call for proper implementation and ethical standards in Nigerian public secondary schools to function appropriately. It disclose slack of concrete therapeutic services as the main problem associated with counselling in secondary schools and presents a training and operational model to address this. The study recommends awareness, training, collaboration as well as an up-to-date record keeping of data in order to help students effectively to achieve their desired educational goals and a better quality of life.

In Sri Lanka, record keeping in rheumatology clinics is purely paper-based. Clinic record books are given to patients, and the hospital does not retain clinical data. Different clinics and different rheumatology specialists practice different formats of record keeping in Sri Lanka. This project was aimed to develop a uniform record keeping system which can be used in all government rheumatology clinics in Sri Lanka. Project was carried out in two phases. First phase was carried out in seven rheumatology clinics to identify deficiencies in existing practice of record keeping in rheumatoid arthritis (RA), spondyloarthritis (SPA), and systemic lupus erythematosus (SLE). Second phase was to develop new clinic documents and a computer-based system, using the findings of the first phase. Recording of classification criteria at the time of diagnosis was 40.6% for RA and 90.3% for SLE. Initial clinical notes were not available in 18.3% of RA patients. Recording of individual classification criteria in SPA was ranged between 10% and70%, and it was 100% for arthritis. During second phase, new paper-based and computer-based record keeping systems were developed. Existing practice of record keeping is incomplete, especially in RA and SPA. The necessity of new, uniform record keeping system was recognized. Paper-based and computer-based record keeping systems acceptable to specialist rheumatologists, medical officers, and the Ministry of Health were developed and tested. The newly developed paper-based system is being used nationally while the electronic system is yet to introduced.

Record-keeping can seem merely administrative, but it should be an essential part of care home operations. Adrian Ashurst discusses the importance of teaching staff how to develop daily and medicine records encompassing all aspects of care and support

Background: A functional newborn care corner (NBCC) is critical to provide immediate care to newborns including resuscitation, warmth, and initial care to sick newborns. NBCC provides an acceptable environment for all infants at birth, and it is mandatory for all delivery points at all levels in the health system including operation theaters. Objective: The objective of this study was to find the status of availability of NBCCs and service provision in selected public health facilities of Bihar. Methods: A total of 57 NBCCs, having high delivery load (>100 deliveries/month), across 25 high-priority districts in Bihar, were selected purposively in consultation with the State Health Society, Bihar, for the assessment. These facilities were assessed for the availability and/or functioning of infrastructure, equipment maintenance, human resource, supply of drugs and consumables, adherence to protocols, and record keeping. Results: Only 22.8% of the NBCCs were found to be fully functional, majority (68.4%) were partially functional, and 9% were nonfunctional. Thirty-seven (64.9%) NBCCs were located inside the labor room premises. Approximately, one-third of the neonates delivered were kept in NBCCs. Equipment though available lacked the provision of annual maintenance contract. Essential drugs such as adrenaline (24.6%) and Vitamin K injection (42.1%) were not available in many facilities. Only 6.2% of the newborns had low birth weight, indicating underreporting. Majority of the health-care staff available were trained but possessed poor skills. Data recording and reporting was also suboptimal. Conclusion: The network of NBCCs needs to be strengthened across the state and linked with higher facilities to achieve the desired reduction in neonatal morbidity and mortality.

In the XXI century moral depreciation concept comprises not only deterioration of outside appearance of construction elements in the course of time but accelerated fashion changes in respect of interior design and rapid increase in technical level for residence buildings. For this reason if average rate of building dilapidation in the buildings of series 1–335, 1–335А and 1–464А constructed in Minsk within the period of 1957–1975 and being operated till 2005–2006 has constituted 25–29 % and their moral depreciation has been equal to more than 40 % then rate of the moral depreciation has significantly increased in the XXI century. Such situation requires execution of special investigations. High operating rates of refinancing have led to the necessity for record keeping of initial expenses and repairability levels because selection of building construction, repair or reconstruction variant depends on these parameters. Repairability classification of main elements of residence buildings and premises has been proposed for regulation of such selection procedure. In this case it is recommended to take into account technological effectiveness of repair and technical service, verifiability, accessibility, easy dismountability, substitutability and interchangeability of construction elements and technical devices. The paper presents nomograms that permit to make easier practical calculations on determination of cost-efficient time period for operation of the element prior to its substitution at various refinancing rates and also for comparison of relative initial expenses according to time service.

The study was conducted in Benue State, Nigeria to assess prospects of rural youths participation in family farming. Data were collected from a sample of eighty (80) respondents using questionnaire/interview schedule. Frequency, percentage, mean score, standard deviation and factor analysis were used for analyzing data. Majority (75%) of the respondents were males, not married (63.70%), about 99% had formal education, having a mean age of 24 years. Major activities engaged by rural youths in family farming were clearing of farm lands (M = 2.62), harvesting of crops (M = 2.61), irrigating of farm lands (M = 2.39), staking of crops (M = 2.35), sorting/grading of farm produce (M = 2.35), gathering of fruits (M = 2.34) and applying fertilizer to crops (M = 2.33). Results also indicate prospects of rural youths participation in family farming which include proper farm record keeping (M = 2.66), increase in household food security (M = 2.60), increase in farm labour (M = 2.58), provision of market information for sales of farm produce (M = 2.58), increase in household income (M = 2.55), proper preservation of seeds and seedling/planting materials (M = 2.54), increase on the use of modern farming techniques (M = 2.53), increase in farm yields (M = 2.50, among others. The study thus recommends that rural youths should be supported to remain in family farming through adequate provision of labour-saving technologies and modern farm implements to ease operations and ensure optimum productivity. It also highlights that efforts of service providers are needed in providing youths in rural areas with necessary infrastructure such as electricity in order to discourage them from migrating to urban areas.

Patients with injuries to the midface frequently sustain ophthalmic injuries and fractures to the facial bones. Despite this, basic ophthalmic examination and assessment of important clinical signs are often missing from the records of patients attending the emergency department (ED). We implemented a structured record keeping tool to improve documentation for patients presenting to the ED with midface injuries.At our institution, a structured record keeping tool was introduced to document important clinical features of maxillofacial injuries. This assessment tool included 17 key clinical diagnostic signs and symptoms including a six-part basic ophthalmic examination. We audited 369 patients attending the ED with suspected midface bony injuries using this tool.A statistically significant improvement in the documentation of all six ophthalmic parameters was seen. The documentation rate of visual acuity increased by 41.1% (SE 2.8; p0.001); diplopia by 45% (2.9; p0.001); double vision by 51% (2.9; p0.001); lateral subconjunctival haemorrhage with no posterior limit by 83% (2.6; p0.001) and enopthalmous by 86% (2.4; p0.001). Documenting whether pupils were equal and react to light increased by 14% (1.4; p0.001). In addition, 10 out of 11 non-ophthalmic parameters showed significant improvement. The mean global record keeping score increased from 45.3% (95% CI 42.7% to 47.7%) to 99.1% (95% CI 98.2% to 100%; p0.001).This work demonstrates that a structured record keeping tool is a simple and effective method of significantly improving clinical documentation for patients with facial injuries presenting to the ED.

In his continuing series looking at the legal and professional implications of the Nursing and Midwifery Council's revised Code of Conduct, Richard Griffith discusses the elements of accurate record keeping under Standard 10 of the Code. This article considers the importance of accurate record keeping for the safety of patients and protection of district nurses. The legal implications of records are explained along with how district nurses should write records to ensure these legal requirements are met.