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1. Documentation and Coding for Patient Safety Indicators (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
   March 15, 2016 - In summary, effective documentation and coding processes involve the following key steps: • Documentation … Documentation by Providers Because coders can use only documentation from the treating providers that … rates based on their current style of documentation, side by side with revised rates after documentation … Documentation and Coding Issues for Individual QIs Some specific documentation issues for the PDIs are … Documentation by Providers SAMPLE QUERY FORM Clinical Documentation Improvement Training Ways To

2. Documentation Guidance for Use of 1135 Skilled Nursing Facility (SNF) Waivers | Agency for Healthcare Research and Quality
   www.ahrq.gov/nursing-home/resources/documentation-guidance.html
   May 01, 2022 - Documentation Guidance for Use of 1135 Skilled Nursing Facility (SNF) Waivers Resource: Documentation

3. The Future of Diagnostic Documentation | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact5.html
   July 01, 2024 - : Exploring the Impact of Electronic Health Records on Diagnostic Safety The Future of Diagnostic Documentation … History of EHR Documentation Legislation Challenges and Opportunities for Improvement in Diagnostic … Documentation The Future of Diagnostic Documentation Conclusion References The … Future advancements in EHR documentation can address a range of factors, including increased provider … without negatively affecting provider documentation burden.

4. History of EHR Documentation Legislation | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact3.html
   July 01, 2024 - Diagnosis: Exploring the Impact of Electronic Health Records on Diagnostic Safety History of EHR Documentation … History of EHR Documentation Legislation Challenges and Opportunities for Improvement in Diagnostic … Documentation The Future of Diagnostic Documentation Conclusion References The … Regulations affect diagnostic documentation by promoting standardization, interoperability, and patient … Data capture and EHR documentation were identified as key health management functions and categorized

5. Challenges and Opportunities for Improvement in Diagnostic Documentation | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact4.html
   July 01, 2024 - Exploring the Impact of Electronic Health Records on Diagnostic Safety Introduction on Diagnostic Documentation … History of EHR Documentation Legislation Challenges and Opportunities for Improvement in Diagnostic … Documentation The Future of Diagnostic Documentation Conclusion References Accurate … and robust documentation affects the standard of care. … Enhanced documentation enables well-organized availability of meaningful, accurate, and complete health

6. Compendium of U.S. Health Systems, 2023, Technical Documentation (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2023-compendium-techdoc.pdf
   January 01, 2023 - HEALTH SYSTEMS, 2023, TECHNICAL DOCUMENTATION 1 I. … HEALTH SYSTEMS, 2023, TECHNICAL DOCUMENTATION 3 II. … HEALTH SYSTEMS, 2023, TECHNICAL DOCUMENTATION 7 III. … HEALTH SYSTEMS, 2023, TECHNICAL DOCUMENTATION 8 1. … HEALTH SYSTEMS, 2023, TECHNICAL DOCUMENTATION 9 2.

7. Documentation of BMI percentile and weight classification for children | Agency for Healthcare Research and Quality
   www.ahrq.gov/pqmp/measures/documentation-bmi-percentile.html
   August 01, 2021 - Documentation of BMI percentile and weight classification for children Measure Domain:  Management

8. Documentation and Coding for the AHRQ Pediatric Quality Indicators (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
   March 15, 2016 - In summary, effective documentation and coding processes involve the following key steps: • Documentation … Documentation by Providers Because coders can use only documentation from the treating providers that … rates based on their current style of documentation, side by side with revised rates after documentation … Documentation and Coding Issues for Individual PDIs Some specific documentation issues for the PDIs … Documentation and Coding for the AHRQ Pediatric Quality Indicators Addressing the Documentation and

9. Conclusion | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact6.html
   July 01, 2024 - Exploring the Impact of Electronic Health Records on Diagnostic Safety Introduction on Diagnostic Documentation … History of EHR Documentation Legislation Challenges and Opportunities for Improvement in Diagnostic … Documentation The Future of Diagnostic Documentation Conclusion References EHR … Detailed documentation enhances patient safety by reducing the risk of diagnostic errors and facilitating … However, specific knowledge about diagnostic errors within EHR documentation is limited, indicating a

10. Introduction on Diagnostic Documentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact2.html
    July 01, 2024 - Exploring the Impact of Electronic Health Records on Diagnostic Safety Introduction on Diagnostic Documentation … History of EHR Documentation Legislation Challenges and Opportunities for Improvement in Diagnostic … Documentation The Future of Diagnostic Documentation Conclusion References The … EHRs enhance patient safety both directly and indirectly by improving data documentation, ensuring data … to increase the quality and utility of clinical documentation.

11. Compendium of U.S. Health Systems, 2022, Technical Documentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2022-Compendium-TechDoc.pdf
    January 01, 2022 - Health Systems, 2022, Technical Documentation Comparative Health System Performance Initiative: Compendium … Health Systems, 2022, Technical Documentation Prepared for: Agency for Healthcare Research and Quality … For more information about hospital-to-hospital matching, refer to the technical documentation for the … Health Systems, 2022, Technical Documentation Contents Tables Figures Acknowledgments I. … Health Systems, 2022, Technical Documentation is appropriate for this document.

12. Compendium of U.S. Health Systems, 2020, Technical Documentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/2020-Compendium-TechDoc.pdf
    January 01, 2020 - Health Systems, 2020, Technical Documentation Comparative Health System Performance Initiative: Compendium … Health Systems, 2020, Technical Documentation Prepared for: Agency for Healthcare Research and Quality … v The Hospital Linkage File and technical documentation for the Compendium of U.S. … Health Systems, 2020, Technical Documentation Acknowledgments I. Introduction II. … Health Systems, 2020, Technical Documentation is appropriate for this document.

13. Compendium of U.S. Health Systems, 2021, Technical Documentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/2021-Compendium-TechDoc.pdf
    January 01, 2021 - Health Systems, 2021, Technical Documentation Comparative Health System Performance Initiative: Compendium … Health Systems, 2021, Technical Documentation Prepared for: Agency for Healthcare Research and Quality … iv The Hospital Linkage File and technical documentation for the COMPENDIUM OF U.S. … Health Systems, 2021, Technical Documentation Acknowledgments I. Introduction II. … Health Systems, 2021, Technical Documentation is appropriate for this document.

14. Compendium of U.S. Health Systems, 2021, Technical Documentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2021-Compendium-TechDoc-rev.pdf
    January 01, 2021 - Health Systems, 2021, Technical Documentation Comparative Health System Performance Initiative: Compendium … Health Systems, 2021, Technical Documentation Prepared for: Agency for Healthcare Research and Quality … For more information about hospital-to-hospital matching, refer to the technical documentation for the … iv The Hospital Linkage File and technical documentation for the Compendium of U.S. … Health Systems, 2021, Technical Documentation is appropriate for this document.

15. Compendium of U.S. Health Systems, 2020, Technical Documentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2020-Compendium-TechDoc-rev.pdf
    January 01, 2020 - Health Systems, 2020, Technical Documentation Comparative Health System Performance Initiative: … Health Systems, 2020, Technical Documentation Prepared for: Agency for Healthcare Research … For more information about hospital-to-hospital matching, refer to the technical documentation for the … v The Hospital Linkage File and technical documentation for the Compendium of U.S. … Health Systems, 2020, Technical Documentation is appropriate for this document.

16. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/exercises5.html
    December 01, 2017 - : Report Information: Entire Facility Sample Completeness Report: Entire Facility Documentation … 78.2 86.9 Behaviors 53.1 69.9 87.1 91.0 Discussion Questions Which documentation … 54.8 61.7 78.2 86.9 Behaviors 53.1 69.9 87.1 91.0 Evening Shift Documentation … 54.8 61.7 78.2 86.9 Behaviors 53.1 69.9 87.1 91.0 Night Shift Documentation … What areas of documentation need some followup investigation? Why?

17. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/8.html
    December 01, 2017 - Report Description The Completeness Report is a check of CNA documentation to determine how much of … On-Time Reports are generated from four sections of CNA documentation: Meal Intake, Bowels, Bladder, … Report Example Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13 Meal Intake … Bowels CNA documentation of bowel habits Includes: All residents on a unit during each week. … Behaviors CNA documentation of behaviors Includes: All residents on a unit during each week.

18. Compendium of U.S. Health Systems, Technical Documentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/chsp/data-resources/compendium/technical-documentation.html
    December 01, 2023 - Health Systems, 2022, Technical Documentation (PDF, 1 MB). Compendium of U.S. … Health Systems, 2021, Technical Documentation  (PDF, 6 MB). Compendium of U.S. … Health Systems, 2020, Technical Documentation  (PDF, 2 MB). Compendium of U.S. … Health Systems, 2018, Technical Documentation  (PDF, 1.3 MB). Compendium of U.S. … Health Systems, 2016, Technical Documentation  ( updated January 2019 ) (PDF, 2 MB).

19. Hypertension Screening for Children Who Are Overweight or Obese: Tables 3-5 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-tables3-5.pdf
    June 02, 2025 - that BMI is ≥85th percentile 6 6 (100) 1 Documentation of blood pressure contained in the medical … of height 6 6 (100) 1 Documentation of weight 6 6 (100) 1 Table 4: Documentation of Blood Pressure … of Systolic Blood Pressure Percentile 5 207 2.4% Documentation of Diastolic Blood … Pressure Percentile 5 207 2.4% Documentation of Blood Pressure Classification As Normal … of Blood Pressure Percentile for Children with Calculated BMI ≥85th Percentile Table 5: Documentation

20. CHIPRA 230: Section 6, Tables 6 and 7 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-230-section-6-table-6-7.pdf
    June 02, 2025 - of BMI percentile 59 58 (98) 0.982 Documentation of weight classification 59 55 (93) 0.924 Documentation … of height 59 59 (100) 1 Documentation of weight 59 59 (100) 1 Table 7: Documentation of BMI Percentile … and Weight Classification Measure Numerator (N) Denominator (N) Proportion (%) Documentation … of BMI Percentile 192 600 32.0% Documentation of Weight Classification 219 600 36.5% Documentation … 517 600 86.2% Documentation of Weight 576 600 96.0%