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Showing results for "documentation".
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www.ahrq.gov/pqmp/measures/adolescents-psychotic-disorder.htmlAugust 01, 2021 - Children/adolescents admitted to the hospital with a diagnosis of psychotic disorder should have documentation
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Sample Adherence Report (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/skills/sample-adherence-report.docxMarch 01, 2022 - Electronic medical record—generate reports based upon bathing documentation from a routine nursing shift … The following is an example of a daily adherence report generated from a nursing documentation query. -
www.ahrq.gov/pqmp/measures/followup-discussion.htmlAugust 01, 2021 - Children/Adolescents Admitted to the Hospital for Dangerous Self-Harm or Suicidality Should Have Documentation
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www.ahrq.gov/pqmp/measures/outpatient-follow-up.htmlAugust 01, 2021 - Children discharged from the hospital should have documentation in their hospital medical record that
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc_pilotstudy.pdfApril 01, 2015 - Near-Miss Documentation by ASC Type ASC Type Near-Miss Documentation Multispecialty Single Specialty … Near-Miss Documentation by ASC Ownership ASC Ownership Near-Miss Documentation Not Hospital Affiliated … Near-Miss Documentation by ASC Size Number of Surgery/Procedure Rooms Near-Miss Documentation … Near-Miss Documentation by Staff Position Staff Position Near-Miss Documentation Doctor/Physician … Near-Miss Documentation by ASC Type Table 14.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra-16-p001-3-ef.pdfApril 01, 2016 - Reliability was assessed by comparing the eMeasure output with the results of abstraction of documentation … measure are available in structured, queriable fields and that these fields are used for routine documentation … ● Reasons that patient records did not meet the measure included: no documentation of referral feedback … eMeasure was not implementable at that site at this time, but it would be feasible with clinician documentation … where the EHR includes all of the measure elements in structured, queriable fields and where routine documentation
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Chipra118-Materials Ii (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA118-Materials_II.pdfJune 02, 2025 - 740 Neonates not born in hospital/medical care setting Neonates for whom the hospital provides documentation … Documentation if child met local criteria for hypothermia and time so identified xi. … Documentation if hypothermia was planned or initiated before temperature taken xii. … If transferred is there documentation that neonate was not born in a medical facility EXCLUDE if: … Documentation child was eligible for and received therapeutic hypothermia (when appropriate). -
AHRQ Slide Template 2004 (ppt file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/spectorhudak.pptDecember 01, 2013 - Challenges for managing clinical risk Residents' changing risk profiles not readily available Daily documentation … criteria Identify information needs of all disciplines Incorporate data elements into existing clinical documentation … efforts Provide functional specifications for any vendor Use existing vendor software features for documentation -
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/care/resources/ontime/pruprev/spectorhudaktxt.htmlDecember 01, 2017 - Daily documentation is fragmented across disciplines. … Incorporate data elements into existing clinical documentation (e.g., nurse, dietary & CNA). … Use existing vendor software features for documentation.
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Sample Adherence Report (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/skills/sample-adherence-report.pdfMarch 01, 2022 - Electronic medical record—generate reports based upon bathing documentation from a routine nursing shift … The following is an example of a daily adherence report generated from a nursing documentation query -
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/overview/background/measures-CC-13.pdfDecember 16, 2010 - Numerator: The number of patients in the denominator sample who have documentation of date and result … This is defined by documentation of a face-to-face visit for diabetes care between the physician and
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh48.htmlApril 01, 2018 - electronic medical record [EMR] review or floor visit), each leading to verification step and an independent documentation … Documentation leads to monthly aggregation of SSI cases that is used in reporting.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cap-toolkit/tool4b_pc-setting.pptxJanuary 10, 2017 - Acknowledgment of this BPA is required only when completing the visit, but it is not required for other documentation … Acknowledgment of this BPA is required only when completing the visit, but it is not required for other documentation … Acknowledgment of this BPA is required only when completing the visit, but it is not required for other documentation … Acknowledgment of this BPA is required only when completing the visit, but it is not required for other documentation
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www.ahrq.gov/diagnostic-safety/index.htmlJanuary 01, 2007 - Impact of Electronic Health Records on Diagnostic Safety Reviews the history of documentation … legislation, including rules and regulations, challenges, and best practices to improve documentation
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Ncinqtobaccousehelpform (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/NCINQTobaccoUseHelpForm.pdfAugust 01, 2012 - Documentation that the adolescent is not a tobacco user OR Documentation that the adolescent is a … Appropriate guidance and encouragement of healthy lifestyles (or documentation of smoking/tobacco use … Rates vary from a low of 44.5% percent documentation to a high of 85.3 percent. … There were substantial variations by site in documentation of tobacco status. Table 11. … This uptake was seen in field test results for smoking status documentation. -
The Impact of Health Information Technology on Work Process and Patient Care in Labor and Delivery (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Campbell_47.pdfMarch 11, 2008 - Prior to this study, all obstetric clinical care documentation was handwritten as free-text progress … was paper-based, and in August 2006, 5 months after the full integrated release, when all documentation … Figure 1 shows an example of the STORC interface, and Figure 2 provides an example of STORC documentation … As previously mentioned, STORC is a clinical documentation system that does not provide order-entry … The shift to an EHR certainly provides a ripe opportunity to determine if clinical care documentation -
Advantages and Disadvantages of Registries (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/registries-pros-cons.pdfJune 02, 2025 - Requires hardware, software, and maintenance • Requires data entry and data maintenance • Parallel documentation … some information has to be entered in two systems) • Can’t stand alone, must have an additional documentation -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices.docxJune 02, 2025 - ASK: Does your facility have standardized prevention procedures and documentation for medical devices … ASK: How do you review or audit documentation now? … A problem was identified with inconsistent or absent documentation of present on admission (POA) skin … The failure to have clear admission documentation led to an increase in the documentation of hospital-acquired … · Computer documentation that ties assessment directly to the care plan saves time.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptxMay 01, 2017 - Such aids help teams have a shared mental model and efficient approach for management and documentation … It can also foster accurate and comprehensive documentation, which can be critical for a medical liability … Reformat or build customized content into unit’s existing documentation systems. 34 AHRQ Safety Program … Shoulder dystocia: management and documentation. Semin Perinatol. 2014 Jun;38(4):194-200. … Improvement in documentation using an electronic checklist for shoulder dystocia deliveries.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdfMarch 21, 2008 - Of these eight, two had medication documentation errors. … The chart review identified 66 additional errors, mostly documentation errors; 16 of the errors (19.1 … Although the numbers were small, there was a trend for documentation errors to increase as the number … For example, an after-hours snapshot might reveal an even larger volume of documentation errors, since … Incomplete medical record documentation can pose a serious hazard to the patient.
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