Clinical Documentation

/Tag:Clinical Documentation

HM2018 Abstract Number: Top 15 Research & Innovations

TAKING NOTE: HOW MANY NOTES DO HOSPITALISTS LOOK AT WHEN WRITING H&PS?

Background: Recent widespread adoption of electronic health records (EHRs) has dramatically increased the amount of information quickly accessible to clinicians. Given recent pushes for interoperability and consumer generated data in EHRs, the volume of information [...]

By | 2018-03-29T15:35:07-04:00 March 29th, 2018|Hospital Medicine 2018, Top 15 Research and Innovation Oral Abstracts|Comments Off on TAKING NOTE: HOW MANY NOTES DO HOSPITALISTS LOOK AT WHEN WRITING H&PS?

HM2018 Abstract Number: 223

SCRIBES IN HOSPITAL MEDICINE- A POWERFUL VALUE-ADDED RESOURCE!

Background: Since the advent of Electronic Health Record(EHR) and subsequent workload of clinical documentation, Hospital Medicine physicians are finding themselves spending more time in front of the computer and less with their patients. The implementation [...]

By | 2018-03-19T13:24:45-04:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Quality Improvement|Comments Off on SCRIBES IN HOSPITAL MEDICINE- A POWERFUL VALUE-ADDED RESOURCE!

HM2018 Abstract Number: 186

Pediatric Clinical Documentation Queries with Definitions: An Innovative Way to Promote Provider Engagement

Background: Clinical Documentation Improvement programs have been present in adult hospitals for many years. These programs strive to promote clinicians working together with nurse specialists to appropriately depict the care delivered and increase coding accuracy. [...]

By | 2018-03-19T13:17:10-04:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Pediatrics|Comments Off on Pediatric Clinical Documentation Queries with Definitions: An Innovative Way to Promote Provider Engagement

HM2017 Abstract Number: 239

HOW ORIGINAL: CHARACTERIZING THE SOURCE OF TEXT IN PROGRESS NOTES

Background: The original goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the provider’s thought processes.  Electronic health records (EHRs) allow physicians to supplement traditional manual data entry [...]

By | 2017-04-26T02:42:59-04:00 April 20th, 2017|Research Abstracts, Technology in Hospital Medicine|Comments Off on HOW ORIGINAL: CHARACTERIZING THE SOURCE OF TEXT IN PROGRESS NOTES