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There has been little research or development effort toward standardizing the documentation in perinatal medical records. Such variation contributes to data inconsistencies an the inability to equate perinatal nursing interventions with corresponding perinatal outcomes. Further, process measurement tools, such as a perinatal failure to rescue (P-FTR) tool endorsed by the AHRQ, are difficult to implement because of the inability to retrieve the elements from perinatal medical records.
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ICN Conference and CNR 19-23 June 2015 in Seoul.
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