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psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - 2014 or 2015, and many of the comments about the
work experience related to how much time it takes to document
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psnet.ahrq.gov/issue/triad-vii-do-prehospital-providers-understand-physician-orders-life-sustaining-treatment
September 15, 2021 - Study
TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents?
Citation Text:
Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf…
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psnet.ahrq.gov/issue/charting-diagnostic-safety-exploring-patient-provider-discordance-medical-record
April 13, 2022 - Study
Charting diagnostic safety: exploring patient-provider discordance in medical record documentation.
Citation Text:
Giardina TD, Vaghani V, Upadhyay DK, et al. Charting diagnostic safety: exploring patient-provider discordance in medical record documentation. J Gen Intern Med. 2025;…
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psnet.ahrq.gov/issue/adequacy-hospital-discharge-summaries-documenting-tests-pending-results-and-outpatient-follow
September 23, 2020 - Study
Classic
Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.
Citation Text:
Were MC, Li X, Kesterson J, et al. Adequacy of hospital discharge summaries in documenting tests with pending re…
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-newsletter
August 14, 2019 - Copy Citation
Related Resources From the Same Author(s)
ACR guidance document
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psnet.ahrq.gov/issue/are-opioid-dependence-and-methadone-maintenance-treatment-mmt-documented-medical-record
August 15, 2018 - Study
Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.
Citation Text:
Walley AY, Farrar D, Cheng DM, et al. Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patie…
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psnet.ahrq.gov/issue/enhancing-healthcare-process-design-human-factors-engineering-and-reliability-science-part-2
January 16, 2008 - Commentary
Enhancing healthcare process design with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation systems.
Citation Text:
Boston-Fleischhauer C. Enhancing healthcare process design with human factors engineering and reliabilit…
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psnet.ahrq.gov/issue/deficits-discharge-documentation-patients-transferred-rehabilitation-facilities
October 28, 2009 - Study
Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.
Citation Text:
Gandara E, Moniz TT, Ungar J, et al. Deficits in discharge documentation in patients transferred to rehabilitation facilit…
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psnet.ahrq.gov/node/38229/psn-pdf
November 18, 2016 - guidelines and omits
the multiple sub-items that were felt to be too confusing for authors in the initial document
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - their efforts to develop an ACP for this patient with limited capacity, unfortunately, they failed to document
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - tracking and analysis of patient complaint data, mortality and morbidity review, and patient
care document
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - parts of the EHR for medication therapy management purposes; however, only 57% allowed pharmacists
to document … in the EHR.(6) A follow-up 2013 survey found that 62% of hospitals required pharmacists to
document … across the United States to expand their curricula to include the
proper use of the EHR and how best to document
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - She intended to ask where to document an intolerance in the EHR but forgot to ask.
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psnet.ahrq.gov/node/837423/psn-pdf
June 15, 2022 - Evaluation and comparison of errors on nursing notes
created by online and offline speech recognition
technology and handwritten: an interventional study.
June 15, 2022
Peivandi S, Ahmadian L, Farokhzadian J, et al. Evaluation and comparison of errors on nursing notes
created by online and offline speech recogniti…
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psnet.ahrq.gov/node/48103/psn-pdf
June 26, 2019 - An opportunity to engage obstetrics and gynecology
patients through shared visit notes.
June 26, 2019
Herlihy M, Harcourt K, Fossa A, et al. An Opportunity to Engage Obstetrics and Gynecology Patients
Through Shared Visit Notes. Obstet Gynecol. 2019;134(1):128-137. doi:10.1097/AOG.0000000000003309.
https://psnet.a…
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - their efforts to develop
an ACP for this patient with limited capacity, unfortunately, they failed to document
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psnet.ahrq.gov/node/40436/psn-pdf
August 25, 2011 - Hospital discharge documentation and risk of
rehospitalisation.
August 25, 2011
Hansen LO, Strater A, Smith L, et al. Hospital discharge documentation and risk of rehospitalisation. BMJ
Qual Saf. 2011;20(9):773-8. doi:10.1136/bmjqs.2010.048470.
https://psnet.ahrq.gov/issue/hospital-discharge-documentation-and-risk…
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - When informal care occurs, another potential safety issue is the failure to document care or follow … Furthermore, failure to document care exposes the provider to
legal liability.(15)
This case also illustrates … If you choose to treat a colleague, it is wise to document the encounter and provide the same level of
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psnet.ahrq.gov/issue/inaccurate-penicillin-allergy-labeling-electronic-health-record-and-adverse-outcomes-care
December 09, 2020 - Commentary
Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.
Citation Text:
Olans RD, Olans RN, Marfatia R, et al. Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care. Jt Comm J Qual Patient …
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psnet.ahrq.gov/issue/safety-anaesthesia
April 07, 2021 - A position statement and resource document from NAEMSP.