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Showing results for "documentation".
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854849/psn-pdfOctober 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. -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/847046/psn-pdfApril 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 -
digital.ahrq.gov/sites/default/files/docs/citation/r01hs025375-zhou-final-report-2022.pdfJanuary 01, 2022 - Improving Allergy Documentation and Clinical Decision Support in the Electronic Health Record (EHR) - … Final Report Title of Project: Improving Allergy Documentation and Clinical Decision … Many EHRs have limitations in allergy documentation and alerting. … Strategic interventions will enhance allergy documentation quality and related care. … Quality of documentation of contrast agent allergies in electronic health records.
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48123/psn-pdfAugust 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 -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41423/psn-pdfJanuary 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- -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33886/psn-pdfAugust 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. -
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/5.htmlDecember 01, 2017 - Wt Loss ≥7.5% in Prior 90 Days (Point-to-Point) Vital Signs or Weight documentation For each static … Wt Loss ≥10% in Prior 180 Days (Point-to-Point) Vital Signs or Weight documentation For each static … Weekly Meal Intake Average <50% CNA documentation of meal intake For each static week: Count … Daily Urine Incontinence CNA documentation of resident bladder habits For each static week: … >3 Days Bowel Incontinence CNA documentation of resident bowel habits For each static
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38091/psn-pdfFebruary 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 -
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-3.pdfJune 02, 2025 - medication prescribed Note, or medication history Follow-up report about behavioral therapy 11 Documentation … provider), or patient determined to be at risk for harming themselves or others) Note Prescription documentation … or medication list 12 Documentation of system reason(s) for not prescribing behavior therapy as
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www.ahrq.gov/chsp/data-resources/compendium-2016.htmlMarch 01, 2021 - Excel (2.7 MB) CSV file (3.9 MB) Technical Documentation Technical Documentation Report … Data Dictionary (PDF, 329 KB) Compendium Hospital Linkage File, Technical Documentation (PDF, … Data Dictionary – Hospital Linkage File (PDF, 191 KB) Group Practice Linkage File, Technical Documentation
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digital.ahrq.gov/ahrq-funded-projects/barriers-and-facilitators-implementation-and-adoption-ehr-home-careJanuary 01, 2023 - Quantitative data on EHR usage, patient outcomes, clinical documentation completion, reimbursement, and … Its use did significantly improve clinician’s time-to-completion of documentation and timing for submission … Opportunities in interdisciplinary care team adoption of electronic point-of-care documentation systems … Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and … Interdisciplinary care team adoption of electronic point-of-care documentation systems: an unrealized
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digital.ahrq.gov/ahrq-funded-projects/standardization-and-automatic-extraction-quality-measures-ambulatory-electronicJanuary 01, 2023 - CMH standardized and integrated data capture for quality-of-care measurement into the normal documentation … The standardization efforts include both tools and processes for physician documentation, medication … in an ambulatory EMR can be captured in data elements readily available for automated extraction if documentation … In addition, automated data extraction relied heavily on documentation queries, and without incentives … and feedback, providers may not use the documentation queries that are needed for accurate quality measurement
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.htmlDecember 01, 2017 - Weight 90 Days Prior Vital Signs or Weight documentation The weight of the resident approximately … Weight 30 Days Prior Vital Signs or Weight documentation The weight of the resident approximately … Weight Change (lbs) Vital Signs or Weight documentation Change in weight (lbs) from the previous … ≥2% Weight Loss (From Previous Week) Vital Signs or Weight documentation Displays the … ≥5 lb Weight Loss in Prior 30 Days Vital Signs or Weight documentation Displays the value
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/erepguide-slides.htmlDecember 01, 2017 - Nursing assistant documentation. Therapy records. Physician/NP/PA orders. … Bowel and bladder documentation. Activities of daily living. … , vital signs, lab results, physician orders, and other documentation in the EMR. … Count the number of shifts for which documentation is available. … What areas of documentation need some followup investigation?
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38178/psn-pdfOctober 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: -
On-Time - Menu of Implementation Strategies (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/pruprev-menu.pdfJune 02, 2025 - Internal nutritional review; MDS assessment documentation 7. … MDS assessment documentation 8. Root cause analysis for new pressure ulcer development 9. … MDS assessment documentation 6. Root cause analysis for new pressure ulcer development 7. … MDS assessment documentation 5. Nurse/rehab weekly huddle 6. … MDS assessment documentation 5. Root cause analysis for new pressure ulcer development 6. -
hcup-us.ahrq.gov/tech_assist/index_def.jspApril 01, 2021 - Agreements - SEDD Data Use Agreements - SID Data Use Agreement (DUA) Training Tutorial Database Documentation … - KID Database Documentation - NASS Database Documentation - NEDS Database Documentation - NIS … Database Documentation - NRD Database Documentation - SASD Database Documentation - SEDD Database … Documentation - SID Database Releases Databases Department of Health and Human Services Diagnoses
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digital.ahrq.gov/national-webinars/improving-health-it-safety-through-use-natural-language-processingJanuary 01, 2023 - Improving Health IT Safety through the Use Natural Language Processing to Improve Accuracy of EHR Documentation … development of innovative tools and methods designed to advance health IT safety through improved EHR documentation
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/CHSP_2016_GPLF_tech_Dec2020.pdfJanuary 01, 2016 - Group Practice Linkage File Technical Documentation 7 I. … /md-ppas/data-documentation Group Practice Linkage File Technical Documentation 9 For each physician … Group Practice Linkage File Technical Documentation 10 B. … Group Practice Linkage File Technical Documentation 20 4. … Group Practice Linkage File Technical Documentation 26 4.
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IMPLEMENT California Asthma QI Collaborative (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sfmeasures.pdfJune 02, 2025 - If persistent, documentation of: mild, moderate, or severe. … Inclusions: Includes documentation of severity within the past 6 months, or more often if needed … Information sheet for additional clarification/information. 4 Asthma Action Plan Updated Definition: Documentation … Documentation that they saw a pulmonologist or allergist specific to their asthma also counts.
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