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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33850/psn-pdf
    January 01, 2018 - EHR Copy and Paste and Patient Safety January 1, 2018 Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety Perspective Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38817/psn-pdf
    April 04, 2011 - Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. April 4, 2011 Were MC, Li X, Kesterson J, et al. Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. J Gen Intern Med. 2009;24(9)…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60745/psn-pdf
    October 01, 2020 - surgical setting is to either waste any leftover product immediately after administration or to fully document … of both non-controlled and controlled substances.5 Many ADCs provide the ability to electronically document
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861838/psn-pdf
    January 31, 2024 - The pharmacist would document the adverse drug effect in the medical record and alert the prescriber
  5. psnet.ahrq.gov/issue/comparison-accuracy-physical-examination-findings-initial-progress-notes-between-paper-charts
    May 11, 2022 - Study Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record. Citation Text: Yadav S, Kazanji N, C. NK, et al. Comparison of accuracy of physical examination findings in initial progress note…
  6. psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
    January 01, 2024 - operation it is the professional responsibility of the circulating OR Nurse to supervise, manage and document
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38741/psn-pdf
    June 24, 2009 - community-based and 4 academic primary care practices and discovered a 7.1% rate of failure to inform (or document
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50368/psn-pdf
    September 25, 2019 - A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. September 25, 2019 Bourgeois FC, Fossa A, Gerard M, et al. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. J Am Med Inform As…
  9. psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
    March 27, 2024 - This would have been a vital piece of information for the resident to obtain and document on the initial … Generally, as on the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm (POLST document  … significant confusion in a cohort of emergency department physicians when asked to review the POLST document … representative, decision-maker, or proxy; or erroneously referred to as “POA” or power of attorney, which is a document … to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document
  10. psnet.ahrq.gov/issue/investigating-impact-cognitive-bias-nursing-documentation-decision-making-and-judgement
    July 13, 2022 - Study Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement. Citation Text: Martin K, Bickle K, Lok J. Investigating the impact of cognitive bias in nursing documentation on decision‐making and judgement. Int J Mental Health Nurs. 2022;31(4)…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39399/psn-pdf
    February 17, 2011 - Can electronic clinical documentation help prevent diagnostic errors? February 17, 2011 Schiff G, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? New Engl J Med. 2010;362(12):1066-1069. doi:10.1056/NEJMp0911734. https://psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37247/psn-pdf
    December 15, 2011 - Perinatal clinical decision support system: a documentation tool for patient safety. December 15, 2011 Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs Womens Health. 2007;11(4):407-10. https://psnet.ahrq.gov/issue/perinatal-clinical-decision-support-syst…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43401/psn-pdf
    August 02, 2015 - to inform primary clinicians about important clinical issues that arose overnight and also did not document
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43617/psn-pdf
    September 24, 2016 - This study is one of the first to document clinical consequences of physician interruptions and adds
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45344/psn-pdf
    January 23, 2017 - Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record. January 23, 2017 Yadav S, Kazanji N, C. NK, et al. Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a ne…
  16. psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
    June 28, 2023 - The pharmacist would document the adverse drug effect in the medical record and alert the prescriber
  17. psnet.ahrq.gov/issue/development-checklist-documenting-team-and-collaborative-behaviors-during-multidisciplinary
    November 08, 2012 - Study Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds. Citation Text: Henneman EA, Kleppel R, Hinchey KT. Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside r…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41396/psn-pdf
    May 23, 2012 - In search of common ground in handoff documentation in an intensive care unit. May 23, 2012 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. https://psnet.ahrq.gov/issue/search-c…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49838/psn-pdf
    August 01, 2018 - specified location in the medical record, accessible to all members of the interdisciplinary team, to document … Huddle's discussion is documented in the electronic medical record; addendums to this note can be used to document … communication about changes in plans, an area in the medical record where all clinicians can read and document
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854848/psn-pdf
    October 31, 2023 - The bone pathologist then went on vacation for several days but did not document his discussions with … We recommend that the surgical team also document intraoperative consultation results within the operative

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