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Retrieval of the nursing documentation from the electronic patient record was done by the department secretary, who copied it, scored the patients' personal details and then removed personal identifying information before handing it over to the reviewers.
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Examples of my experience include triaging, obtaining medical records, setting appointments and documentation in the electronic health record.
All diagnoses were verified based on documentation in the electronic medical records by one of the investigators (SD or AM).
The data were extracted independently by both raters, using information from the electronic nursing documentation and from the paper-based fever chart of each patient.
Documentation and timing of advance directive (AD) completion were abstracted from the electronic medical record.
Coupled with the transition of medical documentation from paper to electronic storage, computer technology has helped to facilitate changes in data collection for clinical research.
Second, information which formed the basis of our analyses were taken from the electronic health record, and supported by other legal documentation.
13) Unplug from the electronic world occasionally.
Patients' characteristics and risk factors were documented prospectively in the electronic documentation system of our institution.
Documentation of CKD on the electronic problem list is rare.
A Medicare administrative contractor, National Government Services, said recently that it would deny payment for treatments using "cloned documentation" copied from electronic records rather than individualized patient notes composed by doctors and nurses to show medical necessity.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com