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Of the 700 randomly selected records that met these criteria, 601 (85.9%) had a progress note on the day of care, and 553 (92%) of these were found by chart review to have evidence of SUD treatment.
Of the 592 records generated from a non-SUD specialty outpatient clinic that had a HEDIS-qualified SUD diagnosis/CPT code combination, 539 (91%) had a progress note on the day of care, of which 338 (63%) were found by chart review to have evidence of SUD treatment.
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Patient time on the EMR was calculated from first date of a progress note and a physician bill on the same date to the date of the most recent data extraction.
"Prior to the study, I simply documented with a brief sentence or two on a progress note in the patient's chart.
He is the meticulous type, so meticulous that one of his progress notes on a patient's daily chart was cited by nitpickers in Mount Sinai's records department as the perfect note.
Every morning and late afternoon, physicians in hospitals "round" on their patients, discussing their decisions in small groups or writing progress notes on patients' charts.
In these cases, we extracted all of the progress notes on the day of interest.
Because of this, at the time of the study, some participants were already typing ePNs, while others still wrote progress notes on paper, or dictated them for transcription.
To satisfy the clinical reminders, the clinician must first create a new progress note in the EHR, then click on an icon to display a list of reminders that are due, and then click on individual reminders to invoke a dialogue box to address each one.
Telephone counselors enter an electronic progress note into the EMR to document the telephone counseling and the participant's preference for pharmacotherapy and designate the primary care provider and/or the smoking cessation clinician(s) as additional signers on the progress notes.
During the birth-cohort phase, a reminder sticker was placed on each progress note for every visit (Fig. 1).
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com