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461. Inhaled Corticosteroids for Children With Persistent Asthma Prescribed at Time of Discharge From the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-212-fullreport.pdf
     September 01, 2018 - Administrative data (e.g., claims data); paper medical record; electronic medical record. … Medical Record Abstraction Medical record data were obtained through HealthCore, Inc., for the 2013 … and paper medical records into a password-protected database. … This measure requires medical record abstraction; medical records are maintained by all health services … This measure requires medical record abstraction; medical records are maintained by all health services

462. 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/exercises4.html
     December 01, 2017 - Summary Report often highlights opportunities for facilities to improve existing processes to capture and record

463. 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/6.html
     December 01, 2017 - determine increase in urinary and bowel incontinence are provided in two ways to support the ways CNAs may record

464. Chapter 2: Building and Assessing the Clinic Foundation | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/obesity/obpcp2.html
     May 01, 2014 - you and your practice are performing (or not performing) certain tasks as reflected in the medical record … Note that as electronic health record technology advances, it may be feasible to obtain data on the clinic's

465. National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) Training—Overview National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) Component | Agency for Healthcare Research and Quality
     www.ahrq.gov/nursing-home/resources/nhsn-training-overview.html
     April 01, 2022 - National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) Training—Overview National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) Component Resource: National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) Training—Overview National Healthcare Safety Network …

466. CHIPRA 194: Section 5, Table 11, Figures 1 and 2 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-section-5-table-11-figs-1-2.pdf
     April 21, 2015 - Retrospective study Lateef et al. examined the records of 364 children 2 to 5 years of age who presented … Retrospective study Gandhi et al. completed a retrospective medical record review of children 2 to … They randomly selected 141 charts for review out of a possible 1,076 patient records.

467. Webcast: Using Just Culture To Improve Hospital SOPS Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/events/webinars/just-culture.html
     December 01, 2018 - Webcast: Using Just Culture To Improve Hospital SOPS Results November 9, 2016 Summary Speakers and Presentation Slides Recordings Transcript Summary On November 9, 2016, the Agency for Healthcare Research and Quality (AHRQ) hosted a webcast featuring Just Culture initiatives that helped improve …

468. Instructions for Analyzing Data from CAHPS Surveys (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/2020-instructions-for-analyzing-data.pdf
     January 01, 2020 - The macro checks for missing values in each case and determines whether to keep the record based on the … USEN Number of usable records for PLAN USENTXT Number of usable records for PLAN (stored as a character … If used, the plan detail file must have a unique record for each plan name or code. … CHILD and set it equal to 1 for child records and some other value, usually 0 for adult records. … Any record with a missing value is dropped from the analysis.

469. Future Vision for Probabilistic Diagnostic Decisions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking4.html
     September 01, 2022 - incorporating links to available data, such as the CDC COVID Data Tracker , into electronic health records

470. Puh-Erepguide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.pdf
     February 10, 2014 - full benefit of the On-Time reports, including rules to determine risk for slow healing, staff must record … which physician orders to use for report displays; it will depend on what the electronic medical record

471. TeamSTEPPS® Diagnosis Improvement: Module 6 Mutual Support - Facilitator’s Notes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module6-presenters-notes.pdf
     January 10, 2022 - For example, an office nurse could say to a records clerk, “I am concerned about Mr. … I am uncomfortable not changing his medication without reviewing records from the provider who cared … but could you please call the practice where he received care previously and ask them to send his records … The receptionist and the records clerk share responsibility for updating patient files and facilitating … The records clerk likes to start her day with followup from the day before.

472. Module 6: Mutual Support
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module6-mutual-support.pptx
     January 10, 2022 - For example, an office nurse could say to a records clerk, “I am concerned about Mr. … I am uncomfortable not changing his medication without reviewing records from the provider who cared … The receptionist and the records clerk share responsibility for updating patient files and facilitating … The records clerk likes to start her day with followup from the day before. … Example: A physician in the practice begins to routinely extend her lunch break to work on patient records

473. PCIC Staff Qualitative Interview Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-pcip-staff-ny.pdf
     June 02, 2025 - PROMPT: Could be related to a change in patient care or the way you are using the Electronic Health Record

474. Final Progress Report: Electronic Clinical Surveillance To Measure and Improve Safety in Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
     January 01, 2024 - It adopted an electronic health record in 2006 that contains information on diagnoses, procedures, … Data on patient-, provider-, and system-level factors were pulled from the electronic health record … In some cases, medical record reviews were conducted on a sample of records to support data cleaning … Limitations of our study include the retrospective use of electronic health record data, which was … For example, improvements to the electronic health record might help reduce multiple care gaps.

475. New CAHPS Tools for Patient Experience Measurement (Webcast) | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/news-and-events/events/webinar-062525.html
     July 01, 2025 - New CAHPS Tools for Patient Experience Measurement (Webcast) June 25, 2025 Contents Summary Speakers Slides and Recording Summary This free webcast from AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program detailed new innovative tools to enhance patient experience measurement. Lear…

476. PQMP Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/measures/index.html?page=3
     Admitted to the Hospital for Dangerous Self-Harm or Suicidality, Should Have Documentation in the Hospital Record … Admitted to the Hospital for Dangerous Self-Harm or Suicidality Should Have Documentation in the Hospital Record … CAPQuaM) Children admitted to the hospital should have documentation in their hospital medical record … of a transition record Measure Domain: Management of Acute Conditions Measure Subdomain: Transitions … COE4CCN) Children discharged from the hospital should have documentation in their hospital medical record

477. 4. Assessment of the Intervention | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen4.html
     April 01, 2018 - using the electronic records to uncover evidence of screening. … performed colonoscopies, there was only limited evidence of colonoscopy in the primary care EMR or billing records … The central entity could not begin to review electronic records to identify eligible patients (Step 3 … review as opposed to updating enrollment records. … Some said there was a flowsheet in the paper records that recorded screenings, whereas others used an

478. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - Reports also require elements from other data sources, including physician orders, medication records … Reports also require elements from other data sources, including physician orders, medication records … If no diagnosis is in the medical record, the cell will be blank. … If no diagnosis is in the medical record, the cell is blank. … Electronic data sources such as nurse documentation, 24-hour reports, electronic medication administration records

479. SOPS® Health Information Technology (IT) Supplemental Item Set for the SOPS Hospital Survey (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/HIT-Patient-Safety-Item-Set-English-12-15-22.docx
     December 01, 2022 - Respondents who answer “No” to the first question: “Do you use your hospital’s Electronic Health Record … is intended for those who enter or review patient information in your hospital’s electronic health record … SafetyCultureSurveys@westat.com Last updated: December 2022 Your Hospital’s Electronic Health Record … Do you use your hospital’s Electronic Health Record (EHR) system(s) to enter or review patient information … Information was entered into the wrong patient health record.......................................

480. Patient Self-Management Support of Chronic Conditions: Framework for Clinicians Seeking Recertification Credit (MOC Part IV & PI-CME) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/continuing-ed/moc-sms.html
     October 01, 2020 - to document patient self-management support—such as asking about health goals—in patients’ medical records