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Four e-learning modules addressed 19 patient cases on symptoms, diagnostics and treatment, and a chart-documentation exercise.
Diagnosis of HIV infection was identified by a positive ELISA/Western blot test or indicated by a provider in chart documentation based on patient history.
We calculated a percentage for chart documentation in each of the three parameters (antimicrobial regimen/indication, duration, and de-escalation).
While the presence of chart documentation has a good positive predictive value for detecting delirium, the absence of chart documentation cannot reliably exclude delirium in an ICU population.
Chart documentation of a pharmacist-initiated IV-PO conversion was recorded in 3/27 (11%) episodes in Phase I and 4/23 (17%) episodes in Phase II.
As an example, it is often unclear from chart documentation whether the error occurred because of a lack of monitoring or in the course of adhering to recommended medication monitoring.
Increasingly detailed chart documentation was observed after ASP, with an increase in formally documented stop dates, as well as reductions in antimicrobial use and costs after ASP implementation.
Antibiotics that were documented as given, but without clear chart documentation of the associated timing, were coded as ambiguous-timing.
However, the sensitivity and PPV were over 90% for the chart documentation of RA diagnosis in a study of Medicare diagnosis claims for RA from several rheumatology practices [ 4].
This two-part study examines primary care clinicians' chart documentation and attitudes when confronted by a positive waiting room screen for intimate partner violence (IPV).
Of the 700 inpatient/residential records generated from a non-addiction specialty unit that had a HEDIS-qualified SUD diagnosis, only 5 lacked associated chart documentation and only 321 of the remaining 695 (46.2%) had chart review evidence of addiction treatment.
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com