Sentence examples for chart documentation from inspiring English sources

Antibiotics that were documented as given, but without clear chart documentation of the associated timing, were coded as ambiguous-timing.

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.

Chart documentation presumably reflects issues thought important enough by the doctor to document in the chart.

These documented field data were retrospectively supplemented with data from the emergency physician chart documentation.

Patients were excluded for inadequate chart documentation or lack of follow-up for at least 12 months.

Increasingly detailed ICU chart documentation was available after ASP.

Coders code medical events after discharge based on chart documentation.

This phenomenon may underlie the lack of chart documentation.

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.

Without transparent chart documentation, it becomes increasingly difficult for other clinicians to make informed decisions.

Only one other study in the literature examines chart documentation in the ICU [ 14].