Today that documentation occurs, but often by the bands themselves, with flip cameras and mobile phones.
Documentation errors occurred in 65 of 1,934 prescribed agents (3.5%).
Google Glass enables us to document our environment without any indication or signal that this documentation is occurring.
Furthermore, as is common in unpredictable environments like the ED, HPI documentation may occur before or after the decision to obtain imaging or admit the patient.
This means that the hard coded medical domain knowledge in the system results in higher cost when new requirements in clinical documentation routines occur.
Improvement of documentation might occur through medical informatics, which The Institute of Medicine's report To Err is Human[ 40] suggested might decrease medical errors and enhance patient safety.
Poor documentation, when it occurred, involved poor handwriting on the MDM proforma or ambiguous annotations, which gave no clear account of the MDM decision.
The clinical conditions included in the questionnaire were: hypertension, heart failure, angina, COPD, asthma, back-pain, cancer (diagnosed in the past 5 years), stroke, cirrhosis, arthritis (proved by X-ray documentation), myocardial infarction (occurred in the past 5 years), and stomach ulcer (proved by endoscopy).
When reached by telephone, Dr. Chalasani defended his work, saying the 2008 findings were the result of poor documentation about what had occurred before the patients received the catheterizations.
As an example, it is often unclear from chart documentation whether the error occurred because of a lack of monitoring or in the course of adhering to recommended medication monitoring.
