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Neither used clinical outcomes but focused instead on comprehensiveness of documentation.
We intended to merely describe the comprehensiveness of documentation in the medical record and not its accuracy.
Principles that influence the redesign of workflows include simplicity, accessibility for patients, safety, comprehensiveness of documentation, and delegation.
The primary outcomes were the encounter time (defined as the time from reviewing patient information to assessing the patient and completing charting) and comprehensiveness of documentation.
In the current study we set out to identify the comprehensiveness of documentation of communication abilities within the EHR at a large academic medical center.
Our study found that the comprehensiveness of documentation of neonatal resuscitation and stabilization of VLBW infants varies significantly across institutions, and that many potentially important items indicative of the quality of the resuscitation were missing from the medical record.
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To determine the comprehensiveness of neonatal resuscitation documentation and to determine the association of various patient, provider and institutional factors with completeness of neonatal documentation.
Aims: To quantify the frequency of unplanned readmission among cardiac surgery patients at a large teaching hospital; to identify reasons for readmission and to ascertain the comprehensiveness of related hospital documentation.
This is the first study to examine the comprehensiveness of neonatal resuscitation documentation among multiple institutions, and to identify associated factors.
We also described the level and comprehensiveness of clinical record documentation, microbiology laboratory and coding data at identifying HAUTIs and CAUTIs.
A smart solution would be to include the codes in a new chapter regarding clinical health promotion in the classifications and preserve simplicity and comprehensiveness of this new field of documentation and registration.
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