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  1. 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
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Harney_89.pdf
    May 01, 2007 - Design/Methods: We screened 1,340 inpatient records for recommended dose of anticoagulant, indication … The retrospective review included a review of medical records of patients aged 18 years or younger that … Medical records were reviewed to assess compliance with three major aspects of care: (1) recommended … Results of the screening were documented in each patient’s medical record using a templated form. … In 2007, a hospital-wide automated medical record was introduced, and the template is now required for
  3. 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
  4. www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/cahptab.html
    December 01, 2017 - There are also costs for collecting other HEDIS® measures, particularly if medical records review is
  5. www.ahrq.gov/patient-safety/reports/engage/appe.html
    March 01, 2017 - Definition: Health information technology can include mobile messaging, telemedicine, electronic health records
  6. www.ahrq.gov/news/newsroom/case-studies/cquips0605.html
    October 01, 2014 - Staff with indirect patient contact included, among others, registration and medical records personnel
  7. www.ahrq.gov/news/newsroom/case-studies/ktcquips94.html
    October 01, 2014 - organizations—including hospitals and outpatient settings—and is compatible with both paper-based and electronic medical records
  8. www.ahrq.gov/research/findings/final-reports/ssi/ssiexecsum.html
    April 01, 2018 - involved developing and testing a computer-assisted algorithm for retrospective assessment of medical records
  9. www.ahrq.gov/research/findings/final-reports/iomracereport/reldata3.html
    May 01, 2018 - Collecting and maintaining demographic data in medical records and enrollment files allows for analyses … at least OMB race and Hispanic ethnicity data in specific circumstances, such as in administrative records … Table 3-2 shows the categories used by various federally funded health surveys, state birth records, … Hospital Discharge Data Hospital discharge records sometimes lack race and ethnicity information ( … collect, classify, consolidate, and link information on new cancer cases from hospital reports, medical records
  10. www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-7.html
    July 01, 2022 - whenever possible, although other resources (e.g. family, caregivers, community pharmacies, past medical records … This list should be documented in a single location within the medical record that is utilized and is
  11. www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-7.html
    July 01, 2022 - whenever possible, although other resources (e.g. family, caregivers, community pharmacies, past medical records … This list should be documented in a single location within the medical record that is utilized and is
  12. 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.......................................
  13. www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas3-2.html
    October 01, 2013 - Notes Types of health information technology could include: personal health records, activity logs, … or appointment reminder systems that may be linked to electronic health records.
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Stock_113.pdf
    June 15, 2005 - created electronically by integrating data from the Shared Care Plan, a Web-based personal health record … , and clinic electronic medical records (EMRs) to create a single, Web-based view. … This Web page, called “Meds On Record” (MOR), was available within the SCP medication list function. … “Meds On Record” Functionality With patients entering medication data into their SCPs and health care … “Meds On Record” functionality diagram.
  15. www.ahrq.gov/patient-safety/reports/engage/appa.html
    March 01, 2017 - Oral agreement to audio record will be recorded. … Oral agreement to audio record will be recorded.
  16. www.ahrq.gov/takeheart/training/implementing-automatic-referral/index.html
    April 01, 2023 - systematic, automatic referral of all qualifying patients to CR through the hospital electronic health record … implementing, and troubleshooting an automatic referral system within your hospital’s electronic health record
  17. www.ahrq.gov/policymakers/chipra/demoeval/demostates/wy.html
    March 01, 2019 - Ensuring the CME utilizes or interfaces with Wyoming's total health record (THR) for health home and … electronic health record (EHR) functions. … Care Quality To support enhanced care coordination, Wyoming is (1) integrating an electronic health record … (EHR) into its total health record (THR) system and (2) making the THR system accessible to CME operations
  18. www.ahrq.gov/research/findings/final-reports/iomracereport/reldatafig51txt.html
    May 01, 2018 - ); Other Health Delivery Entities (e.g., nursing homes)   Individual Data Patient Medical Record … Arrows connect Medicare to the State Level and Provider Level Collections, to Patient Medical Record … The Provider Level Collections and Patient Medical Record are linked by arrows to the Regional Quality
  19. www.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
    May 01, 2023 - Larkin's vital signs were accurately recorded in his medical record. The team (including Mr.
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
    January 01, 2004 - analyzing the data.5 Drury6 describes eight human factors observational methods: (1) raw event/time records … Raw event/time records can be useful to analyze the time history of single events, such as in the investigation … The observer uses the area titled comments to record notes about the observation and the names of the … In a later phase of observation, a Tablet PC is used to record data. … There is also room to record notes.

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