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Showing results for "documentation".

41. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38091/psn-pdf
    February 18, 2011 - Questionable hospital chart documentation practices by physicians. … Questionable hospital chart documentation practices by physicians. … https://psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians This study … found that more than half of physicians surveyed engaged in questionable documentation practices, such … behaviors, and the greater impact of billing and medical-legal influences on documentation practices

42. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38178/psn-pdf
    October 29, 2008 - Documentation of clinical review and vital signs after major surgery. … Documentation of clinical review and vital signs after major surgery. … https://psnet.ahrq.gov/issue/documentation-clinical-review-and-vital-signs-after-major-surgery This … Incomplete medical documentation was noted more commonly on the weekends. … https://psnet.ahrq.gov/issue/documentation-clinical-review-and-vital-signs-after-major-surgery https:

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42014/psn-pdf
    February 06, 2013 - Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations … Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations … https://psnet.ahrq.gov/issue/diagnostic-errors-orthopedic-surgery-evaluation-resident-documentation- … This finding raises concerns regarding careful physical examinations and documentation in such patients … https://psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians

44. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40620/psn-pdf
    July 22, 2011 - The role of documents and documentation in communication failure across the perioperative pathway. … The role of documents and documentation in communication failure across the perioperative pathway. … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across- perioperative-pathway … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway … https://psnet.ahrq.gov/issue/documentation-clinical-review-and-vital-signs-after-major-surgery

45. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46847/psn-pdf
    March 28, 2018 - Advance care planning documentation practices and accessibility in the electronic health record: implications … Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications … https://psnet.ahrq.gov/issue/advance-care-planning-documentation-practices-and-accessibility-electronic … - health-record This study found that electronic health record documentation of patients' preferences … Only half of participants had documented preferences available, and the documentation was often difficult

46. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74699/psn-pdf
    January 26, 2022 - Indication alerts to improve problem list documentation. … Indication alerts to improve problem list documentation. … https://psnet.ahrq.gov/issue/indication-alerts-improve-problem-list-documentation Problem lists, while … https://psnet.ahrq.gov/issue/indication-alerts-improve-problem-list-documentation https://psnet.ahrq.gov

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72470/psn-pdf
    January 01, 2021 - safe-use-ehr-medical-scribes-qualitative-study The use of medical scribes for electronic health record (EHR) documentation … is one strategy to shift the burden of documentation away from clinicians. … significant patient safety risks with scribes and highlighted the positive effects scribes have on documentation … rise-medical-scribe-industry-implications-advancement-electronic-health-records https://psnet.ahrq.gov/issue/evaluation-interventions-improve-inpatient-hospital-documentation-within-electronic-health

48. Charting diagnostic safety: exploring patient-provider discordance in medical record documentation. | PSNet
    psnet.ahrq.gov/issue/charting-diagnostic-safety-exploring-patient-provider-discordance-medical-record
    April 13, 2022 - Charting diagnostic safety: exploring patient-provider discordance in medical record documentation … Charting diagnostic safety: exploring patient-provider discordance in medical record documentation. … Charting diagnostic safety: exploring patient-provider discordance in medical record documentation. … 2022 Comparison of a focused family cancer history questionnaire to family history documentation

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44141/psn-pdf
    November 06, 2015 - Failures in communication through documents and documentation across the perioperative pathway. … Failures in communication through documents and documentation across the perioperative pathway. … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across- perioperative-pathway … qualitative study of communication among providers in perioperative care revealed a reliance on written documentation … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37733/psn-pdf
    June 13, 2011 - Survey of medication documentation at hospital discharge: implications for patient safety and continuity … Survey of medication documentation at hospital discharge: implications for patient safety and continuity … https://psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient- … discharged from an inpatient cardiology service had at least one discrepancy in their medication documentation … https://psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient-safety-and-continuity

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39054/psn-pdf
    February 20, 2010 - Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication … Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication … https://psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries- retrospective-analysis … https://psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis … https://psnet.ahrq.gov/issue/accuracy-medication-documentation-hospital-discharge-summaries-retrospective-analysis

52. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records | PSNet
    psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
    May 26, 2021 - 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.

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45197/psn-pdf
    March 20, 2017 - When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation … When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation … psnet.ahrq.gov/issue/when-doctors-share-visit-notes-patients-study-patient-and-doctor-perceptions- documentation … Approximately one-fourth of patients identified a possible documentation error in their records, illustrating … //psnet.ahrq.gov/issue/when-doctors-share-visit-notes-patients-study-patient-and-doctor-perceptions-documentation

54. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46532/psn-pdf
    July 30, 2018 - Efficiency and safety of speech recognition for documentation in the electronic health record. … Efficiency and safety of speech recognition for documentation in the electronic health record. … https://psnet.ahrq.gov/issue/efficiency-and-safety-speech-recognition-documentation-electronic-health … - record Electronic documentation burden can contribute to physician burnout. … https://psnet.ahrq.gov/issue/efficiency-and-safety-speech-recognition-documentation-electronic-health-record

55. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37882/psn-pdf
    July 31, 2008 - Documentation of drug allergy on drug chart in patients presenting for surgery. … Documentation of drug allergy on drug chart in patients presenting for surgery. … https://psnet.ahrq.gov/issue/documentation-drug-allergy-drug-chart-patients-presenting-surgery Nearly …  one in three patients presenting for elective surgery did not have adequate documentation of drug allergies … https://psnet.ahrq.gov/issue/documentation-drug-allergy-drug-chart-patients-presenting-surgery

56. Developing a medical emergency team running sheet to improve clinical handoff and documentation. | PSNet
    psnet.ahrq.gov/issue/developing-medical-emergency-team-running-sheet-improve-clinical-handoff-and-documentation
    June 26, 2024 - Developing a medical emergency team running sheet to improve clinical handoff and documentation … Developing a medical emergency team running sheet to improve clinical handoff and documentation. … Developing a medical emergency team running sheet to improve clinical handoff and documentation.

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37959/psn-pdf
    January 11, 2017 - Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation … Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation … https://psnet.ahrq.gov/issue/deficits-discharge-documentation-patients-transferred-rehabilitation-facilities … discharged from hospitals on anticoagulant medications (including warfarin and heparin) lacked adequate documentation … https://psnet.ahrq.gov/issue/deficits-discharge-documentation-patients-transferred-rehabilitation-facilities

58. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38013/psn-pdf
    March 09, 2009 - Agreement between patient-reported symptoms and their documentation in the medical record. … Agreement between patient-reported symptoms and their documentation in the medical record. … https://psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation- medical-record … https://psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record … https://psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record

59. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39393/psn-pdf
    March 24, 2010 - 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 … https://psnet.ahrq.gov/issue/lack-emergency-medical-services-documentation-associated-poor-patient- … https://psnet.ahrq.gov/issue/lack-emergency-medical-services-documentation-associated-poor-patient-outcomes-validation … https://psnet.ahrq.gov/issue/lack-emergency-medical-services-documentation-associated-poor-patient-outcomes-validation

60. Agreement between patient-reported symptoms and their documentation in the medical record. | PSNet
    psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record
    November 09, 2022 - Study Agreement between patient-reported symptoms and their documentation in the … Agreement between patient-reported symptoms and their documentation in the medical record. … Agreement between patient-reported symptoms and their documentation in the medical record.