There is still scarce and sparse evidence regarding documentation of the subjective, objective, assessment and plan (SOAP) note in community pharmacies despite its long implementation history in clini...
In 2016, an IT system was developed at MUL for the documentation of nursing practice. Preparing nursing students for the implementation of eHealth solutions under simulated conditions is crucially imp...
The system was created through the cooperation of an interprofessional team at the Medical University of Łódź. The ADPIECare system was implemented in 2016 at three universities in Poland, and in 2017...
Over 50% of the surveyed nurses indicated the usability of the system for the "effectiveness of documentation" variable. The same group of respondents had a positive attitude towards patient care plan...
Circadian and multidien cycles of seizure occurrence are increasingly discussed as to their biological underpinnings and in the context of seizure forecasting. This study analyzes if patient reported ...
We retrospectively studied if circadian cycles derived from patient-based reporting reflect the objective seizure documentation in 2003 patients undergoing in-patient video-EEG monitoring....
Only 24.1% of more than 29000 seizures documented were accompanied by patient notifications. There was cyclical underreporting of seizures with a maximum during nighttime, leading to significant devia...
Patient seizure diaries may reflect a cyclical reporting bias rather than the true circadian seizure distributions. Cyclical underreporting of seizures derived from patient-based reports alone may lea...
Electronic systems are increasingly present in the healthcare system and are often related to improved medical care. However, the widespread use of these technologies ended up building a relationship ...
Emergency department (ED) providers face increasing task burdens and requirements related to documentation and paperwork. To decrease the mental task burden for providers, our institution developed an...
Our study aims to analyze the effect of a nonelectronic health record-based infographic, paired with direct feedback, on compliance with nonemergent invasive procedure documentation performed in the E...
This was a retrospective, observational study of all procedure documentation performed in the ED with a pre-/post-test design. The study included two 8-month study periods, 1 year apart. The preimplem...
During the pre- and postimplementation study periods, 486 and 405 charts with nonemergent procedures were identified, respectively. In the preimplementation period, 278 (57%) procedures were compliant...
Implementing an invasive procedure documentation infographic and direct feedback improved overall documentation compliance for nonemergent invasive procedures....
Nurses document wounds to direct and evaluate the care. People admitted to emergency departments with wounds should be regarded as potential forensic patients, requiring meticulous documentation for e...
To explore the documentation of wounds in emergency departments through a forensic lens and compare it between different levels of emergency departments....
In this descriptive retrospective study, we randomly sampled 515 paper-based medical files of patients who sustained wounds admitted to three selected emergency departments. The files were analysed us...
All files included information on the type of wound (100%) and the site of the wound (100%) with most files including the mechanisms of injury (98.6%). Few files included information on blood loss (18...
Wounds were poorly documented in emergency departments, irrespective of the level of care. Nurses in emergency departments should have strict guidelines for documenting wounds since accurate documenta...
In 2021, federal rules from the 21st Century Cures Act mandated most clinical notes be made available in real-time, online, and free of charge to patients, a practice often referred to as "open notes....
Even prior to open notes, how an ethics consultant should document a clinical ethics consultation was widely debated as there can be competing interests, differing moral values, and disagreement about...
We explore implications of open notes for ethics consultation, review clinical ethics consultation documentation styles, and offer recommendations for documentation in this new era....
To identify factors associated with the minimum necessary information to determine an individual’s eligibility for lung cancer screening (ie, sufficient risk factor documentation) and to characterize ...
Cross-sectional observational study using electronic health record data from an academic health system in 2019....
We calculated the relative risk of sufficient lung cancer risk factor documentation by patient-, provider-, and system-level variables using Poisson regression models, clustering by clinic. We compare...
Among 20,632 individuals, 60% had sufficient risk factor documentation to determine screening eligibility. Patient-level factors inversely associated with risk factor documentation included Black race...
We found a low rate of sufficient lung cancer risk factor documentation and associations of risk factor documentation based on patient-level factors such as race, insurance status, language, and patie...
While conducting recombinant DNA technology procedures, such as DNA purification, agarose gel electrophoresis is often used for identification, characterization and quantification of DNA. The collecti...
To analyze how physician clinical note length and composition relate to electronic health record (EHR)-based measures of burden and efficiency that have been tied to burnout....
Secondary EHR use metadata capturing physician-level measures from 203,728 US-based ambulatory physicians using the Epic Systems EHR between September 2020 and May 2021....
In this cross-sectional study, we analyzed physician clinical note length and note composition (e.g., content from manual or templated text). Our primary outcomes were three time-based measures of EHR...
Physician-week measures of EHR usage were extracted from Epic's Signal platform used for measuring provider EHR efficiency. We calculated physician-level averages for our measures of interest and assi...
Physicians in the top decile of note length demonstrated greater burden and lower efficiency than the median physician, spending 39% more time in the EHR after hours (p < 0.001) and closing 5.6 percen...
"Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy....
