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Showing results for "documentation".

161. Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner | PSNet
     psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
     February 26, 2025 - Data dissemination methods via texts and emails to providers to encourage ongoing documentation and increases … Clear documentation of adverse events in a NAPSI quality reporting platform. … When a positive screen occurs, documentation of whether or not the mitigation strategy was applied. … Clear documentation of adverse events in a NAPSI quality reporting platform. … When a positive screen occurs, documentation of whether or not the mitigation strategy was applied.

162. Baffled by Botulinum Toxin | PSNet
     psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
     July 17, 2024 - In this case, poor communication between specialists and a nonstandardized documentation system put the … A robust mechanism of documentation and communication is essential to ensure safety of the injections … In this case, the interventions implemented by the clinic—a combination of standardizing documentation … January 16, 2008 Improving documentation of a beta-blocker quality measure through an … anesthesia information management system and real-time notification of documentation errors.

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43798/psn-pdf
     January 07, 2015 - end of the 19-month pilot program, the service enhanced the quality of final medication lists and documentation … psnet.ahrq.gov/primer/computerized-provider-order-entry https://psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient-safety-and-continuity

164. Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals. | PSNet
     psnet.ahrq.gov/issue/communication-and-information-deficits-patients-discharged-rehabilitation-facilities
     January 11, 2017 - Documentation of important care transition information, such as medication changes and pending test … Citation Related Resources From the Same Author(s) Deficits in discharge documentation

165. Identification of inpatient DNR status: a safety hazard begging for standardization. | PSNet
     psnet.ahrq.gov/issue/identification-inpatient-dnr-status-safety-hazard-begging-standardization
     January 19, 2012 - Documentation could be found in the paper chart or electronic medical record, by means of a color-coded … The authors call for development of national standards for DNR documentation.

166. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
     August 29, 2021 - and recording of medications administered or wasted. 11 Lack of proper documentation can lead to … several additional errors beyond the lack of  documentation. … These same principles apply to the proper timing and documentation of medication waste. … Lack of documentation and failure to follow appropriate procedure when it comes to wasting medications … Experts recommend the best practice for documentation of medication waste in the surgical setting is

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41119/psn-pdf
     July 03, 2016 - https://psnet.ahrq.gov/primer/diagnostic-errors https://psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors … https://psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors https

168. In Conversation With… Robert Hirschtick, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
     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.

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854848/psn-pdf
     October 31, 2023 - a significant barrier to effective communication in this case was the lack of standardized written documentation … consultation diagnosis and the final pathology diagnosis, CAP guidelines require reconciliation and documentation … Systems Change Needed Consistency in Documentation Adherence to a standardized frozen section examination … protocol to ensure consistency in reporting and documentation helps to underpin surgical pathology … As in all fields of medicine, clear and consistent communication and documentation remain essential

170. A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites. | PSNet
     psnet.ahrq.gov/issue/national-survey-assessing-number-records-allowed-open-electronic-health-records-hospitals-and
     May 29, 2019 - systems permit records for multiple patients to be open simultaneously for electronic ordering and documentation … November 3, 2015 Indication alerts to improve problem list documentation.

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41413/psn-pdf
     September 26, 2012 - While documentation of tasks related to discharge were notably improved, integrating these interventions … /critical-conversations-call-nonprocedural-time-out https://psnet.ahrq.gov/issue/hospital-discharge-documentation-and-risk-rehospitalisation

172. Physicians' attitudes towards copy and pasting in electronic note writing. | PSNet
     psnet.ahrq.gov/issue/physicians-attitudes-towards-copy-and-pasting-electronic-note-writing
     March 04, 2015 - 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

173. What can apologies in the electronic health record tell us about health care quality, processes, and safety? | PSNet
     psnet.ahrq.gov/issue/what-can-apologies-electronic-health-record-tell-us-about-health-care-quality-processes-and
     November 18, 2016 - This observational study of the presence of apology documentation in the electronic health record … The authors suggest reviewing apologies in clinical documentation in order to detect errors.

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33709/psn-pdf
     July 01, 2011 - investigations specifically concerned nurses; the remainder tested technology solutions or structured documentation … Third, groups should strongly consider use of a structured electronic documentation template. … The only randomized trial located in the SHM Task Force review showed that use of an electronic documentation … tool reduced the time required to prepare handover documentation and led to higher ratings of handover … It will also be interesting to see how documentation tools and training programs are adapted for use

175. The effects of a 'discharge time-out' on the quality of hospital discharge summaries. | PSNet
     psnet.ahrq.gov/issue/effects-discharge-time-out-quality-hospital-discharge-summaries
     December 31, 2014 - While documentation of tasks related to discharge were notably improved, integrating these interventions … October 16, 2012 Hospital discharge documentation and risk of rehospitalisation.

176. Integrating incident reporting into an electronic patient record system. | PSNet
     psnet.ahrq.gov/issue/integrating-incident-reporting-electronic-patient-record-system
     June 08, 2010 - document any adverse events, in one of 16 predefined categories, as part of their routine clinical documentation … suffer from low physician reporting rates, integration of incident reporting into routine electronic documentation

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49762/psn-pdf
     June 01, 2016 - A packet with the appropriate documentation from the nursing facility was transported with the patient … More importantly, EHRs can provide a critical link between documentation and action, allowing physicians … As this case illustrates, even the best intended system that relies on paper documentation is likely … Such registries attempt to standardize the documentation of patients' wishes and make these available … CC1-03: Documentations of advanced health care directives in the electronic health records: where are

178. When the Indications for Drug Administration Blur | PSNet
     psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
     May 26, 2021 - with this case  State the eight rights of medication administration  Recognize the importance of documentation … practitioner’s order Appropriate and timely assessment of response and consideration of efficacy Complete documentation … are: the right patient, the right drug, the right dose, the right route, the right time, the right documentation … of the 8 “rights” of medication administration including: the right dose, the right time, the right documentation … Documentation of medication administration and thorough communication—preferably a warm handoff—helps

179. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
     January 01, 2020 - • Recognize the importance of documentation all medications • Acknowledge the importance of handoffs … reconciliation upon transition of care, assessment of patient response to medications, accurate and complete documentation … Complete documentation and handoff communication regarding the medication and patient status 5. … Right documentation 7. Right reason 8. … ordered medication is having the intended or an unintended effect. 28 Take-Home Points (2) • Documentation

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49788/psn-pdf
     March 01, 2017 - Another recent review showed that pharmacists are active users of the EHR, especially in the areas of documentation … placed in the EHR includes clinical progress notes, medication reconciliation notes, allergy documentation … A pharmacotherapy capstone course to advance pharmacy students' clinical documentation skills. … Selecting a clinical intervention documentation system for an academic setting. … Pharmacists' documentation in patients' hospital health records: issues and educational implications