We analyzed the visit note for documentation of joint pain and, if present, indications of the level of joint pain using quantitative pain ratings and whether a plan to address joint pain was provided.
We used text-string searches within the EHR clinical progress notes to look for documentation that the clinician discussed prediabetes or its management with the patient using these key search terms: exercise, physical activity, diet, nutrition, weight loss, lifestyle modification/change, healthy lifestyles, diabetes, and prediabetes.
The most common types of clinical text targeted by these systems-discharge summaries and surgical pathology reports-are often dictated and are composed deliberately for clear communication, while other texts like progress notes are written mainly for documentation purposes [ 6].
Because PowerChart was not used to document progress notes or for medication documentation, some respondents reported concurrent documentation in both paper and EMRs whilst others used the care plan and the electronic discharge summary templates to record entire care episodes.
Standards should be set for documentation of safety netting provision in patient notes.
When Pandora was filing its IPO papers, it noted that it had been subpoenaed by a federal grand jury for documentation of its information sharing practices.
It was there that Soni said he figured out one of the most annoying pain points for doctors in any office: writing down notes and documentation.
Figure 1 shows that the most providers used different methods for documentation in the EHR for different sections of the outpatient encounter note.
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