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psnet.ahrq.gov/node/74708/psn-pdf
January 26, 2022 - hospital-acquired COVID-19 infection that include weaknesses in
oversight, patient legal protections, and documentation
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psnet.ahrq.gov/issue/electronic-health-record-use-issues-and-diagnostic-error-scoping-review-and-framework
September 14, 2011 - December 7, 2022
Improving administration and documentation of enteral nutrition support … May 25, 2022
Improving allergy documentation: a retrospective electronic health record
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psnet.ahrq.gov/issue/time-out-procedure-institutional-ethnography-how-it-conducted-actual-clinical-practice
November 06, 2015 - Related Resources From the Same Author(s)
Failures in communication through documents and documentation … November 6, 2015
The role of documents and documentation in communication failure across
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psnet.ahrq.gov/issue/blending-evidence-and-innovation-improving-intershift-handoffs-multihospital-setting
September 23, 2017 - June 8, 2016
Improving allergy documentation: a retrospective electronic health record … 2014
Developing a medical emergency team running sheet to improve clinical handoff and documentation
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psnet.ahrq.gov/issue/incomplete-care-trail-flaws-system
February 17, 2011 - February 17, 2011
Improving allergy documentation: a retrospective electronic health … March 4, 2011
Can electronic clinical documentation help prevent diagnostic errors?
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psnet.ahrq.gov/node/50607/psn-pdf
December 01, 2020 - current-challenges-health-information-technology-related-patient-safety
https://psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration-contributes-and
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psnet.ahrq.gov/node/836834/psn-pdf
March 30, 2022 - This
collection of resources examines data and documentation involving one nursing home chain to reveal
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psnet.ahrq.gov/node/50568/psn-pdf
October 23, 2019 - user-generated patient information and automatically compiled EHR data in the I-
PASS format can reduce documentation
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psnet.ahrq.gov/node/48136/psn-pdf
August 07, 2019 - provides evidence-based safe practices and
recommendations for improvement, including standardizing documentation
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psnet.ahrq.gov/node/50534/psn-pdf
October 16, 2019 - This systematic
review found evidence that team meetings, error documentation, and trigger algorithms
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - The intern was surprised to see that there was no documentation of any in-depth discussions of the patient's … Finally, in this multi-institutional study, 15% of these older hospitalized patients did not have any documentation … geared to the needs of individual clinical areas, may be necessary to address the communication and documentation … Such an approach would include: (i) ongoing audits of communication, decision-making, and documentation … their communication and decision-making skills; and (iv) standardizing order sets to enable accurate documentation
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psnet.ahrq.gov/node/863221/psn-pdf
February 28, 2024 - tools can be leveraged in primary care and provides several examples, such as
supporting clinician documentation
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psnet.ahrq.gov/node/854629/psn-pdf
October 18, 2023 - electronic health record (EHR) issues (downtime, workflow)
negatively impacted patient safety such as documentation
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psnet.ahrq.gov/node/843323/psn-pdf
February 01, 2023 - of the Inspector General include heightened evaluation and oversight of
medication use and better documentation
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psnet.ahrq.gov/node/74044/psn-pdf
November 03, 2021 - challenges-requiring-five-characters-during-adc-drug-searches-override
https://psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk
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psnet.ahrq.gov/node/73189/psn-pdf
April 28, 2021 - checklists
https://psnet.ahrq.gov/issue/surgical-ward-round-checklist-improving-patient-safety-and-clinical-documentation
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psnet.ahrq.gov/node/48082/psn-pdf
June 19, 2019 - As with prior studies, medication
documentation in hospital discharge summaries remains highly variable
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - One such gap was appropriate chart documentation. … Before the first administration of a new
chemotherapy regimen, chart documentation of the treatment … plan should be readily available.(6) At
minimum, such documentation should include the patient diagnosis … Prior to chemotherapy administration, transparent chart documentation should be available, which
includes
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - www.ncbi.nlm.nih.gov/pubmed/13753341
Case: Forgotten Turn (5)
Upon review of the records, there was no documentation … since her time in the ED, which likely led to the rapid development of this pressure ulcer.
*
*
Documentation … of Pressure Ulcers
Appropriate documentation is not just part of the nursing assessment
Physicians … stay
CMS denial of reimbursement for pressure ulcers that develop in hospital is based on physician documentation
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - This case led to a system-wide analysis of practices regarding allergy documentation in the EHR and development … recording is it possible to understand the context of the reaction later on in the patient's care as such documentation … If the only documentation is "penicillin allergic" (without a description of the actual reaction and … Admission Due to High-Dose Methotrexate Drug Interaction
January 1, 2009
Documentation