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Showing results for "documentation".

101. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49659/psn-pdf
     July 01, 2012 - The patient, who was ultimately discharged from the ED, never suffered any harm from the documentation … Documentation not only summarizes and communicates clinical care, it also serves as a record of care … Increased focus on auditing and feedback of provider notes may improve clinical documentation practices … Can electronic clinical documentation help prevent diagnostic errors? … Time spent on clinical documentation: a survey of internal medicine residents and program directors.

102. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. | PSNet
     psnet.ahrq.gov/issue/clarifying-adverse-drug-events-clinicians-guide-terminology-documentation-and-reporting
     February 03, 2011 - Study Clarifying adverse drug events: a clinician's guide to terminology, documentation … Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. … Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37947/psn-pdf
     May 04, 2010 - Computerized physician order entry of medications and clinical decision support can improve problem list documentation … Computerized physician order entry of medications and clinical decision support can improve problem list documentation … added to an existing computerized provider order entry system, improved the accuracy of physician documentation

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37606/psn-pdf
     January 10, 2017 - with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation … with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation … Building on part 1, this article describes how to apply human factors concepts to the design of clinical documentation

105. Workplace factors associated with burnout of family physicians. | PSNet
     psnet.ahrq.gov/issue/workplace-factors-associated-burnout-family-physicians
     July 03, 2016 - physicians found that a chaotic work environment and the time burden related to electronic health record documentation … December 19, 2018 Improving documentation of a beta-blocker quality measure through an … anesthesia information management system and real-time notification of documentation errors.

106. Information handoff and outcomes of critically ill patients transferred between hospitals. | PSNet
     psnet.ahrq.gov/issue/information-handoff-and-outcomes-critically-ill-patients-transferred-between-hospitals
     July 18, 2016 - This retrospective study of transfers from outside hospitals to intensive care units found that documentation … was often incomplete and lack of documentation was associated with higher in-hospital mortality. … 2015 Developing a medical emergency team running sheet to improve clinical handoff and documentation

107. Sloppy and Paste | PSNet
     psnet.ahrq.gov/web-mm/sloppy-and-paste
     February 02, 2011 - The patient, who was ultimately discharged from the ED, never suffered any harm from the documentation … Documentation not only summarizes and communicates clinical care, it also serves as a record of care … Increased focus on auditing and feedback of provider notes may improve clinical documentation practices … Can electronic clinical documentation help prevent diagnostic errors? … Time spent on clinical documentation: a survey of internal medicine residents and program directors.

108. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866444/psn-pdf
     August 07, 2024 - This issue brief explores the importance of documentation, legislation supporting its quality, and reasons … psnet.ahrq.gov/primer/electronic-health-records https://psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors

109. The impact of introducing medical emergency team system on the documentations of vital signs. | PSNet
     psnet.ahrq.gov/issue/impact-introducing-medical-emergency-team-system-documentations-vital-signs
     January 18, 2011 - Study The impact of introducing medical emergency team system on the documentations … The impact of introducing medical emergency team system on the documentations of vital signs. … Implementation of a medical emergency team improved documentation of vital signs, but did not improve … The impact of introducing medical emergency team system on the documentations of vital signs. … January 4, 2012 Documentation of clinical review and vital signs after major surgery.

110. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. | PSNet
     psnet.ahrq.gov/issue/lack-emergency-medical-services-documentation-associated-poor-patient-outcomes-validation
     June 14, 2017 - Study Lack of emergency medical services documentation is associated with poor patient … Lack of emergency medical services documentation is associated with poor patient outcomes: a validation … Lack of emergency medical services documentation is associated with poor patient outcomes: a validation

111. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33885/psn-pdf
     August 01, 2019 - It's the documentation and in-basket work that put people over the edge. … SS: What we did at UCSF was think about where is the most burdensome part of the documentation for the … In our inpatient practice, they usually have residents and fellows who can help with documentation, … but in ambulatory they have to do the documentation on their own. … But the documentation burden is so different than it was before the EHR became ubiquitous.

112. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. | PSNet
     psnet.ahrq.gov/issue/patient-and-family-reporting-system-perceived-ambulatory-note-mistakes-experience-3-us
     June 06, 2018 - OpenNotes enables patients and their designated  caregivers  to access medical records and provider documentation … medication adherence  and patient engagement, and that patients may be able to identify  errors  in documentation … effects of implementing a system for patients and families to report mistakes they saw in outpatient documentation

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35467/psn-pdf
     March 11, 2011 - This systematic review discovered that EHRs reduced documentation time for nurses but increased it for … The latter finding of workstation choice is perhaps the most striking, as interpretation of overall documentation … this regard, efforts to implement EHRs will need to address the potential for increased physician documentation

114. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867390/psn-pdf
     December 18, 2024 - patient safety: consider the impact of interventions on physician well-being, reduce the burden of documentation … , offload some documentation to non-physicians/non-clinicians, coordinate training courses, rethink

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/839312/psn-pdf
     November 02, 2022 - This scoping review explored how antimicrobial indication documentation can impact antibiotic use and … research interest and note that emerging evidence indicates that appropriate antimicrobial indication documentation

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38245/psn-pdf
     February 18, 2011 - academic centers and found that copying and pasting was not reported to adversely affect physician documentation … While the study did not examine clinical outcomes or actual errors in documentation, the potential safety … effect-electronic-health-records-ambulatory-care-retrospective-serial-cross-sectional-study https://psnet.ahrq.gov/issue/piece-my-mind-copy-and-paste https://psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk

117. Documenting the indication for antimicrobial prescribing: a scoping review. | PSNet
     psnet.ahrq.gov/issue/documenting-indication-antimicrobial-prescribing-scoping-review
     August 03, 2022 - This scoping review explored how antimicrobial indication documentation can impact antibiotic use and … research interest and note that emerging evidence indicates that appropriate antimicrobial indication documentation

118. EHR Copy and Paste and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
     January 01, 2018 - The use of copy and paste in medical documentation raises many concerns. … Despite widespread acknowledgement by clinicians that the quality of documentation has declined since … Documentation review may need to be incorporated into peer review processes in order to heighten the … accuracy, as patients will now also be able to hold us accountable for quality documentation. … Ultimately, physicians need to reestablish ownership of the accuracy of clinical documentation.

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837900/psn-pdf
     August 24, 2022 - inaccurate-penicillin-allergy-labeling-electronic-health-record-and-adverse- outcomes-care Inadequate or incorrect documentation … This commentary discusses factors contributing to penicillin allergy documentation errors within electronic

120. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48050/psn-pdf
     June 05, 2019 - patients-managing-medications-and-reading-their-visit-notes-survey- opennotes-participants OpenNotes provides patients with access to their health care provider’s documentation … This study found that patient access to such documentation may have the potential to improve medication