There was a significant difference in measures of triage documentation content with CDS (Table 2).
We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an EMR.
We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record.
(After the visit, I learned, while reading a guidebook, that the list of names from Yad Vashem is in fact present at the exhibit — in a separate information center, located under the field of stelae, that is also said to contain a diverse and generous measure of historical documentation. It's not marked prominently, it's not easy to find, and it's not integral to the display).
However, pre- and post-measures of referral documentation in charts, and patient self-reports of referrals revealed no significant increases in overall referral rates.
We measured the quality of documentation as the percentage of essential items contained in the medical record and discharge instructions, the percentage of appropriate testing and treatment decisions, median charges per patient visit, physician satisfaction by pre-experiment and postexperiment questionnaires, and patient satisfaction by telephone questionnaire.
Table 2 shows the unadjusted rates of fulfillment of the five measures of medical record documentation quality for internists and for pediatricians.
We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations.
The primary outcome measures included documentation of do-not-resuscitate orders and comfort care plans, intensity of diagnostic and therapeutic interventions in the last 24 hours of life, and presence of pain and distress in the last 48 hours of life.
