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The diagnosis and outcome of SSTI was based on physician documentation.
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Gage et al showed an increased risk of intracranial hemorrhage (ICH) in patients with AF at high risk of falls (based on physician's documentation in patient's medical record: "frequent falls, history of falls, multiples falls, or tendency for falls") compared to other patients (2.8 versus 1.1 per 100 patient-years).
The original SENSOR-Pesticides model was based on physician reporting.
Assignment was based on physician preference.
IPF progression was based on physician assessment.
All accommodations and services are individualized and based on students needs, course requirements, and appropriate documentation.
Healthcare coders may not identify a diagnosis of sepsis based on the physician's documentation alone.
The accuracy of suspected diagnoses during resuscitation was evaluated based on emergency physicians' preclinical documentation of suspected injuries compared to the diagnoses documented clinically in the patients' charts (AIS severity ≥1).
Although we did not quantify the quality or quantity of documentation, we routinely have all clinic notes evaluated by coding specialists who verify that the level of service chosen by the physician is justified based on the documentation.
Medication use prior to admission was based on the documentation on the medication reconciliation forms or physician's notes (current use vs. non-use).
The disease categories are based on transfer documentation, medical records, and information provided by the patient that has been verified by a physician [ 33].
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com