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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…
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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)…
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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
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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
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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…
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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
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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
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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…
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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
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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)…
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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…
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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…
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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
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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
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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…
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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
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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…
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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…
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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
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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