Implementation of a Clinical Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department.
Sign Up to like & getrecommendations! Published in 2017 at "Journal of the American College of Surgeons"
DOI: 10.1016/j.jamcollsurg.2016.11.010
Abstract: BACKGROUND Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer… read more here.
Keywords: improvement; quality; clinical documentation; surgery department ... See more keywords
Improving Clinical Documentation of Evaluation and Management Care and Patient Acuity Improves Reimbursement as well as Quality Metrics.
Sign Up to like & getrecommendations! Published in 2021 at "Journal of vascular surgery"
DOI: 10.1016/j.jvs.2021.06.027
Abstract: OBJECTIVE Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by… read more here.
Keywords: quality; documentation; reimbursement; clinical documentation ... See more keywords
Clinical Documentation Practice: A Study of Doctors' Medical Documentary Compliance in Government Hospitals in Gampaha District, Sri Lanka.
Sign Up to like & getrecommendations! Published in 2021 at "Hospital topics"
DOI: 10.1080/00185868.2021.1926385
Abstract: Doctors play a key role in health information system through clinical documentation. The study aimed to assess doctors' compliance with national medical documentation standards. The study was carried out in government hospitals having in-ward patient… read more here.
Keywords: clinical documentation; documentation practice; government hospitals; practice ... See more keywords
"Mm-hm," "Uh-uh": are non-lexical conversational sounds deal breakers for the ambient clinical documentation technology?
Sign Up to like & getrecommendations! Published in 2023 at "Journal of the American Medical Informatics Association : JAMIA"
DOI: 10.1093/jamia/ocad001
Abstract: OBJECTIVES Ambient clinical documentation technology uses automatic speech recognition (ASR) and natural language processing (NLP) to turn patient-clinician conversations into clinical documentation. It is a promising approach to reducing clinician burden and improving documentation quality.… read more here.
Keywords: information; asr; documentation technology; ambient clinical ... See more keywords
Characteristics and Challenges of Clinical Documentation in Self-Organized Fast-Paced Medical Work
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DOI: 10.1145/3555111
Abstract: Clinical documentation is a time-consuming and challenging task, especially in time-critical medical settings. Even with a dedicated scribe person, timely and accurate documentation under time constraints is never easy. In this work, we present a… read more here.
Keywords: time; clinical documentation; paced medical; work ... See more keywords
Measuring recovery-oriented rehabilitation language in clinical documentation to enhance recovery-oriented practice
Sign Up to like & getrecommendations! Published in 2023 at "BJPsych Open"
DOI: 10.1192/bjo.2023.14
Abstract: Background Mental health services are encouraged to use language consistent with principles of recovery-oriented practice. This study presents a novel approach for identifying whether clinical documentation contains recovery-oriented rehabilitation language, and evaluates an intervention to… read more here.
Keywords: oriented rehabilitation; clinical documentation; language; recovery oriented ... See more keywords