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We found that a limited share of time is allocated to direct patient contact, but much more time is spent in documentation and charting.
The share of documentation and charting activities is also of interest.
Physicians from both specialties spend a large share of their working time on documentation and charting, as well as on conversation with staff (colleagues and nurses).
After breakfast on my first full day, I attended to patients at morning "sick call" and resumed the task of familiarizing myself with our pharmacy supplies, emergency medical equipment, evacuation procedures, and our medical documentation and charting process.
Physicians on clinical wards performed documentation and charting tasks for almost one third of their time, which is slightly higher than on the emergency ward and in the intensive care unit.
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It will be completed following annual site visits by a team of external assessors who observe team meetings, review documentation and charts, and interview staff and participants.
The classes focused on managing patient-level information using problem lists and medication lists, as well as efficient documentation and chart review.
Different documentation styles and charting practices may have also affected data collection.
The project – including extensive documentation and example charts – is available online on the project repository BitBucket and a Mini-website is provided that is browsable from within the full text HTML version of the article [Additional file 1].
The clinical data, MMSE, ADL, disease type and length of stay, were collected from pre-discharge documentation and patient charts.
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.
Related(20)
documentation and preparing
paperwork and charting
documentation and drawing
documentation and tracking
documentation and mapping
records and charting
documentation and scheduling
documentation and cards
documentation and training
documentation and tax
documentation and explanation
documentation and record
documentation and work
documentation and identity
documentation and casebook
documentation and operation
documentation and communication
documentation and performance
documentation and information
documentation and source
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