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   Articles with "documentation" as a keyword



How to Teach Good EHR Documentation and Deflate Bloated Chart Notes.

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recommendations! Published in 2025 at "AMA journal of ethics"

DOI: 10.1001/amajethics.2025.808

Abstract: Since health care organizations implemented widespread adoption of electronic health records (EHRs), clinicians' notes about patients' care have become longer and more cumbersome, a phenomenon colloquially known as "note bloat." Bulky templates and blocks of data… read more here.

Keywords: deflate bloated; documentation deflate; documentation; teach good ... See more keywords

Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support.

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recommendations! Published in 2024 at "JAMA internal medicine"

DOI: 10.1001/jamainternmed.2024.4123

Abstract: Importance Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden;… read more here.

Keywords: based documentation; time; visit volume; team based ... See more keywords

Assessment of Adherence to Reporting Guidelines by Commonly Used Clinical Prediction Models From a Single Vendor

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recommendations! Published in 2022 at "JAMA Network Open"

DOI: 10.1001/jamanetworkopen.2022.27779

Abstract: Key Points Question What items are collectively requested by model reporting guidelines and does documentation for deployed clinical predictive models report this information? Findings This systematic review combined 15 model reporting guidelines and identified 220… read more here.

Keywords: models single; single vendor; reporting guidelines; documentation ... See more keywords

Ambient Documentation Technology in Clinician Experience of Documentation Burden and Burnout

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recommendations! Published in 2025 at "JAMA Network Open"

DOI: 10.1001/jamanetworkopen.2025.28056

Abstract: Key Points Question Is the use of ambient documentation technology (ADT) associated with changes in clinician experience of documentation burden and burnout? Findings In this survey study of 1430 clinicians from 2 academic medical center… read more here.

Keywords: ambient documentation; documentation burden; documentation technology; clinician experience ... See more keywords

Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial

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recommendations! Published in 2018 at "JAMA Oncology"

DOI: 10.1001/jamaoncol.2018.2446

Abstract: Importance Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited. Objective To determine whether an LHW program can increase documentation of… read more here.

Keywords: satisfaction; health care; health; cancer ... See more keywords

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center

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recommendations! Published in 2018 at "JAMA Surgery"

DOI: 10.1001/jamasurg.2018.0087

Abstract: Importance Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries… read more here.

Keywords: study; trauma; injury surveillance; injury ... See more keywords

Improving Skin Assessment Documentation in the Electronic Health Record to Prevent Perioperative Pressure Injuries.

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recommendations! Published in 2022 at "AORN journal"

DOI: 10.1002/aorn.13573

Abstract: Perioperative leaders at a pediatric trauma hospital initiated an examination of the existing processes for pressure injury prevention. They assembled a workgroup comprising a wound and skin clinical nurse specialist, a nursing informatics specialist, and… read more here.

Keywords: pressure; health record; documentation; electronic health ... See more keywords

Guidelines in Practice: Patient Information Management.

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recommendations! Published in 2022 at "AORN journal"

DOI: 10.1002/aorn.13844

Abstract: Patient information management can involve paper and electronic documentation. Because the patient's health care record (HCR) is a legal document, it must provide an accurate representation of care. The record contains protected health information and… read more here.

Keywords: information; information management; patient information; documentation ... See more keywords

Physicians' needs for drug allergy documentation in electronic health records and allergy alert systems: Results of an end user's survey

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recommendations! Published in 2022 at "Clinical and Translational Allergy"

DOI: 10.1002/clt2.12141

Abstract: inaccurate allergy documentation. This is in line with reports from other institutions. 3 ‐ 6 It is crucial to standardize allergy documentation in structured data entries in EHRs avoiding free ‐ text entries as much… read more here.

Keywords: allergy documentation; needs drug; physicians needs; documentation ... See more keywords

Goals of care documentation by medical oncologists and oncology patient end‐of‐life care outcomes

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recommendations! Published in 2022 at "Cancer"

DOI: 10.1002/cncr.34400

Abstract: Goals of care (GOC) documentation is important but underused. We aimed to improve oncologist GOC documentation and end‐of‐life (EOL) care. read more here.

Keywords: oncology; goals care; end life; care ... See more keywords

3D documentation and classification of incense tree Aquilaria sinensis (Lour.) Spreng. wounds by photogrammetry and its potential conservation applications

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recommendations! Published in 2024 at "Ecology and Evolution"

DOI: 10.1002/ece3.11536

Abstract: Abstract In recent years, illegal felling of and damage to the incense tree Aquilaria sinensis (Lour.) Spreng. have been reported in Hong Kong. Their native populations are under increasingly severe threat. Therefore, the development of… read more here.

Keywords: classification; tree aquilaria; sinensis; conservation ... See more keywords