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Showing results for "documentation".

21. A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation. | PSNet
    psnet.ahrq.gov/issue/national-web-conference-improving-health-it-safety-through-use-natural-language-processing
    May 01, 2017 - Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation … Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation … This webinar discussed voice-generated electronic records as a strategy to augment clinical documentation … Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation

22. Documentation of drug allergy on drug chart in patients presenting for surgery. | PSNet
    psnet.ahrq.gov/issue/documentation-drug-allergy-drug-chart-patients-presenting-surgery
    August 20, 2018 - Study Documentation of drug allergy on drug chart in patients presenting for surgery … Documentation of drug allergy on drug chart in patients presenting for surgery. … Nearly one in three patients presenting for elective surgery did not have adequate documentation of drug … Documentation of drug allergy on drug chart in patients presenting for surgery.

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60707/psn-pdf
    July 22, 2020 - The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes … The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes … https://psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration … The authors conducted a sociotechnical investigation to describe the implementation of a closed-loop documentation … These types of closed-loop systems automate steps in the documentation of medication administration.

24. Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record. | PSNet
    psnet.ahrq.gov/issue/comparison-accuracy-physical-examination-findings-initial-progress-notes-between-paper-charts
    May 11, 2022 - Compared to paper charts, electronic health records offer safety benefits for physician documentation … However, electronic documentation introduces new concerns, such as copy-and-paste practices (which … This study compared physical exam documentation in initial physician progress notes before and after … Trainee physicians' documentation had fewer errors in both paper and electronic formats. … The authors recommend that hospitals discourage copied notes and encourage accurate documentation at

25. Enhancing healthcare process design with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation systems. | PSNet
    psnet.ahrq.gov/issue/enhancing-healthcare-process-design-human-factors-engineering-and-reliability-science-part-2
    January 16, 2008 - 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 … on part 1 , this article describes how to apply human factors concepts to the design of clinical documentation … with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation

26. Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients. | PSNet
    psnet.ahrq.gov/issue/diagnostic-errors-orthopedic-surgery-evaluation-resident-documentation-neurovascular
    December 31, 2014 - Study Diagnostic errors in orthopedic surgery: evaluation of resident documentation … Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations … This finding raises concerns regarding careful physical examinations and documentation in such patients … Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations

27. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care. | PSNet
    psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient-safety-and-continuity
    March 02, 2011 - Study Survey of medication documentation at hospital discharge: implications for … Survey of medication documentation at hospital discharge: implications for patient safety and continuity … patients discharged from an inpatient cardiology service had at least one discrepancy in their medication documentation … Survey of medication documentation at hospital discharge: implications for patient safety and continuity

28. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/843329/psn-pdf
    February 01, 2023 - Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs … Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs … https://psnet.ahrq.gov/issue/improving-administration-and-documentation-enteral-nutrition-support-therapy … After discovering significant issues with ordering, administration, and documentation of EN, this health … https://psnet.ahrq.gov/issue/improving-administration-and-documentation-enteral-nutrition-support-therapy-veteran-affairs

29. The surgical ward round checklist: improving patient safety and clinical documentation. | PSNet
    psnet.ahrq.gov/issue/surgical-ward-round-checklist-improving-patient-safety-and-clinical-documentation
    March 17, 2021 - Study The surgical ward round checklist: improving patient safety and clinical documentation … The surgical ward round checklist: improving patient safety and clinical documentation. … The surgical ward round checklist: improving patient safety and clinical documentation. … March 17, 2021 The devil is in the detail: how a closed-loop documentation system for … When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation

30. Documentation bad habits: shortcuts in electronic records pose risk. | PSNet
    psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk
    March 12, 2014 - Commentary Documentation bad habits: shortcuts in electronic records pose risk. … Citation Text: Documentation bad habits: shortcuts in electronic records pose risk. Dimick C. … Linkedin Copy URL Cite Citation Citation Text: Documentation

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50674/psn-pdf
    November 20, 2019 - The surgical ward round checklist: improving patient safety and clinical documentation. … The surgical ward round checklist: improving patient safety and clinical documentation. … https://psnet.ahrq.gov/issue/surgical-ward-round-checklist-improving-patient-safety-and-clinical- documentation … https://psnet.ahrq.gov/issue/surgical-ward-round-checklist-improving-patient-safety-and-clinical-documentation … https://psnet.ahrq.gov/issue/surgical-ward-round-checklist-improving-patient-safety-and-clinical-documentation

32. Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care. | PSNet
    psnet.ahrq.gov/issue/inaccurate-penicillin-allergy-labeling-electronic-health-record-and-adverse-outcomes-care
    December 09, 2020 - Inadequate or incorrect documentation of patient allergies can lead to patient harm . … This commentary discusses factors contributing to penicillin allergy documentation errors within electronic … December 9, 2020 Improving allergy documentation: a retrospective electronic health record … June 15, 2022 Improving allergy documentation: a retrospective electronic health record

33. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836963/psn-pdf
    April 20, 2022 - Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement … Investigating the impact of cognitive bias in nursing documentation on decision? … https://psnet.ahrq.gov/issue/investigating-impact-cognitive-bias-nursing-documentation-decision-making … https://psnet.ahrq.gov/issue/investigating-impact-cognitive-bias-nursing-documentation-decision-making-and-judgement … https://psnet.ahrq.gov/issue/investigating-impact-cognitive-bias-nursing-documentation-decision-making-and-judgement

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836749/psn-pdf
    March 16, 2022 - Comparison of a focused family cancer history questionnaire to family history documentation in the … Comparison of a focused family cancer history questionnaire to family history documentation in the electronic … https://psnet.ahrq.gov/issue/comparison-focused-family-cancer-history-questionnaire-family-history- documentation … https://psnet.ahrq.gov/issue/comparison-focused-family-cancer-history-questionnaire-family-history-documentation … https://psnet.ahrq.gov/issue/comparison-focused-family-cancer-history-questionnaire-family-history-documentation

35. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837429/psn-pdf
    January 01, 2022 - Improving allergy documentation: a retrospective electronic health record system-wide patient safety … Improving allergy documentation: a retrospective electronic health record system-wide patient safety … https://psnet.ahrq.gov/issue/improving-allergy-documentation-retrospective-electronic-health-record- … https://psnet.ahrq.gov/issue/improving-allergy-documentation-retrospective-electronic-health-record-system-wide-patient … https://psnet.ahrq.gov/issue/improving-allergy-documentation-retrospective-electronic-health-record-system-wide-patient

36. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854849/psn-pdf
    October 31, 2023 - Finally, structured information can be reformatted into coherent clinical documentation. … Documentation dynamics: note composition, burden, and physician efficiency. … Interdisciplinary Optimization of Admission Documentation: Reducing the Bloat. … Two Years After Coding Changes Sought to Decrease Documentation, Notes Remain ‘Bloated’. … Use of electronic clinical documentation: time spent and team interactions.

37. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/847046/psn-pdf
    April 05, 2023 - Indication documentation and indication-based prescribing within electronic prescribing systems: a … Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic … https://psnet.ahrq.gov/issue/indication-documentation-and-indication-based-prescribing-within-electronic … https://psnet.ahrq.gov/issue/indication-documentation-and-indication-based-prescribing-within-electronic-prescribing … https://psnet.ahrq.gov/issue/indication-documentation-and-indication-based-prescribing-within-electronic-prescribing

38. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/48123/psn-pdf
    August 28, 2019 - Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies … https://psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-analysis-clinically-meaningful- documentation … They found clinically relevant differences between the handoff and transfer note documentation in 42% … https://psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-analysis-clinically-meaningful-documentation … https://psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-analysis-clinically-meaningful-documentation

39. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41423/psn-pdf
    January 03, 2017 - Improving documentation of a beta-blocker quality measure through an anesthesia information management … system and real-time notification of documentation errors. … Improving documentation of a beta-blocker quality measure through an anesthesia information management … system and real-time notification of documentation errors. … https://psnet.ahrq.gov/issue/improving-documentation-beta-blocker-quality-measure-through-anesthesia-

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33886/psn-pdf
    August 01, 2019 - As a result, scribes possess varying levels of documentation skills and clinical knowledge. … Previously defined as unlicensed personnel who were not authorized to enter orders, a documentation … Documentation assistants not authorized to submit orders should "pend" them for certified or licensed … Transcribing orders into the EHR while providing documentation assistance is not considered a verbal … Documentation Assistance Provided by Scribes. Washington, DC: Joint Commission; 2018.