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psnet.ahrq.gov/node/43709/psn-pdf
December 04, 2014 - In addition, physicians and nurses used a log to document the need for ongoing
cardiac monitoring and
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psnet.ahrq.gov/node/39456/psn-pdf
May 04, 2010 - Half of the labels contained at least one error,
and the authors document examples of incomplete or
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psnet.ahrq.gov/node/46532/psn-pdf
July 30, 2018 - Efficiency and safety of speech recognition for
documentation in the electronic health record.
July 30, 2018
Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the
electronic health record. J Am Med Inform Assoc. 2017;24(6):1127-1133. doi:10.1093/jamia/ocx073.
https://…
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psnet.ahrq.gov/node/37882/psn-pdf
July 31, 2008 - Documentation of drug allergy on drug chart in patients
presenting for surgery.
July 31, 2008
Farooq M, Kirke C, Foley K. Documentation of drug allergy on drug chart in patients presenting for surgery.
Ir J Med Sci. 2008;177(3):243-5. doi:10.1007/s11845-008-0166-7.
https://psnet.ahrq.gov/issue/documentation-drug-a…
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psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk
March 12, 2014 - Commentary
Documentation bad habits: shortcuts in electronic records pose risk.
Citation Text:
Documentation bad habits: shortcuts in electronic records pose risk. Dimick C. J AHIMA. 2008;79(6):40-43; quiz 45-46.
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psnet.ahrq.gov/issue/search-common-ground-handoff-documentation-intensive-care-unit
March 23, 2011 - Study
In search of common ground in handoff documentation in an intensive care unit.
Citation Text:
Collins S, Mamykina L, Jordan D, et al. In search of common ground in handoff documentation in an Intensive Care Unit. J Biomed Inform. 2012;45(2):307-15. doi:10.1016/j.jbi.2011.11.007. …
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psnet.ahrq.gov/issue/patient-safety-law-protects-some-documents-court-case
May 30, 2012 - Newspaper/Magazine Article
Patient safety law protects some documents in court case.
Citation Text:
Patient safety law protects some documents in court case. Gallegos A.
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - cases, the team sought to identify potential root causes, describe potential corrective
actions, and document
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psnet.ahrq.gov/node/44189/psn-pdf
September 09, 2015 - Variation in printed handoff documents: results and
recommendations from a multicenter needs assessment.
September 9, 2015
Rosenbluth G, Bale JF, Starmer AJ, et al. Variation in printed handoff documents: Results and
recommendations from a multicenter needs assessment. J Hosp Med. 2015;10(8):517-24.
doi:10.1002/jh…
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psnet.ahrq.gov/issue/evaluation-interventions-improve-inpatient-hospital-documentation-within-electronic-health
June 28, 2011 - Review
Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review.
Citation Text:
Wiebe N, Varela LO, Niven DJ, et al. Evaluation of interventions to improve inpatient hospital documentation within electronic health recor…
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psnet.ahrq.gov/node/37959/psn-pdf
January 11, 2017 - Deficits in discharge documentation in patients
transferred to rehabilitation facilities on anticoagulation:
results of a systemwide evaluation.
January 11, 2017
Gandara E, Moniz TT, Ungar J, et al. Deficits in discharge documentation in patients transferred to
rehabilitation facilities on anticoagulation: results…
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - cases, the team sought to identify potential root causes, describe potential corrective actions, and document
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psnet.ahrq.gov/node/42426/psn-pdf
January 14, 2014 - Documenting quality improvement and patient safety
efforts: the quality portfolio. A statement from the
Academic Hospitalist Taskforce.
January 14, 2014
Taylor BB, Parekh V, Estrada CA, et al. Documenting quality improvement and patient safety efforts: the
quality portfolio. A statement from the academic hospitali…
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psnet.ahrq.gov/node/42104/psn-pdf
January 07, 2015 - Challenges to nurses' efforts of retrieving, documenting,
and communicating patient care information.
January 7, 2015
Keenan G, Yakel E, Lopez KD, et al. Challenges to nurses' efforts of retrieving, documenting, and
communicating patient care information. J Am Med Inform Assoc. 2013;20(2):245-51. doi:10.1136/amiajn…
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psnet.ahrq.gov/issue/when-doctors-share-visit-notes-patients-study-patient-and-doctor-perceptions-documentation
October 27, 2021 - Study
When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship.
Citation Text:
Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: a study of p…
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - Actions Decision-making capacity Assess the patient’s decision-making capacity Document … the capacity assessment in the chart Document the discussion with the patient regarding the severity … prescriptions for any new medications (arrange for dispensing of medications to the patient, if possible) Document … s consent, communicate with the patient’s next-of-kin regarding discharge AMA and follow-up plans Document
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psnet.ahrq.gov/node/43615/psn-pdf
January 22, 2016 - The effect of an electronic SBAR communication tool on
documentation of acute events in the pediatric intensive
care unit.
January 22, 2016
Panesar RS, Albert B, Messina C, et al. The Effect of an Electronic SBAR Communication Tool on
Documentation of Acute Events in the Pediatric Intensive Care Unit. Am J Med Qua…
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psnet.ahrq.gov/issue/national-web-conference-improving-health-it-safety-through-use-natural-language-processing
May 01, 2017 - Webinar
A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation.
Citation Text:
A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accura…
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psnet.ahrq.gov/node/40894/psn-pdf
December 10, 2014 - High incidence of medication documentation errors in a
Swiss university hospital due to the handwritten
prescription process.
December 10, 2014
Hartel MJ, Staub LP, Röder C, et al. High incidence of medication documentation errors in a Swiss
university hospital due to the handwritten prescription process. BMC Heal…
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psnet.ahrq.gov/node/40255/psn-pdf
March 02, 2011 - Medication details documented on hospital discharge:
cross-sectional observational study of factors associated
with medication non-reconciliation.
March 2, 2011
Grimes TC, Duggan CA, Delaney TP, et al. Medication details documented on hospital discharge: cross-
sectional observational study of factors associated w…