Articles with "documentation" as a keyword



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

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

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

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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
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Guidelines in Practice: Patient Information Management.

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

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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
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The first documentation of the Nearctic–Paleotropical migratory route of the Arctic Warbler

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Published in 2022 at "Ecology and Evolution"

DOI: 10.1002/ece3.9223

Abstract: Abstract The Arctic Warbler (Phylloscopus borealis) is a cryptically plumed songbird with an uncommon Nearctic–Paleotropical migratory strategy. Using light‐level geolocators, we provide the first documentation of the migratory routes and wintering locations of two territorial… read more here.

Keywords: nearctic paleotropical; paleotropical migratory; arctic warbler; warbler ... See more keywords
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Comparison of genetic testing documentation between genetic counselors and non-genetic counselors.

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Published in 2023 at "Journal of genetic counseling"

DOI: 10.1002/jgc4.1669

Abstract: Implementation of genetic testing in healthcare increases, but access to, and number of, genetics providers remain scarce. This study analyzed the impact of genetic counselor (GC) involvement on frequency of documentation of pre- and post-test… read more here.

Keywords: genetics; genetic testing; test; genetic counselors ... See more keywords
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Improving trainee clinical documentation through a novel curriculum in internal medicine.

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Published in 2022 at "Journal of hospital medicine"

DOI: 10.1002/jhm.27410

Abstract: BACKGROUND Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown. OBJECTIVE The objective of this study was… read more here.

Keywords: time; assessment; curriculum; intervention ... See more keywords
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Point‐of‐Care Ultrasound Work Flow Innovation: Impact on Documentation and Billing

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Published in 2017 at "Journal of Ultrasound in Medicine"

DOI: 10.1002/jum.14284

Abstract: To evaluate the impact that an innovative automated ultrasound (US) work flow, which allows for bedside performance of examination documentation and order placement, has on point‐of‐care US billing compared to ordering US examinations through an… read more here.

Keywords: point care; ultrasound work; documentation; work flow ... See more keywords