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Exact(53)
To increase how much it was paid by Medicare, Tenet assigned codes "without regard to whether such codes were supported by the patients' medical condition and the physician documentation of the diagnoses in the medical records," the suit said.
Physician documentation of the problem list is often lower than desired.
This study sought to design and validate a reliable instrument to assess the quality of physician documentation.
All information was obtained from physician documentation from the time of initial presentation to the most recent encounter.
Factors affecting physician documentation and diagnosis must be further studied to understand the impact on data quality.
The authors developed a natural language processing (NLP) framework that could be used to extract clinical findings and diagnoses from dictated physician documentation.
Similar(7)
For all (100%) EMS operations suggestive of SCD by our screening approaches, we assessed the original EMS protocols and emergency medicine physician documentations.
However, the accuracy of midwives' and physicians' documentation may be questioned.
I read the nurses' and physicians' documentation in the patients' records to get the whole picture".
In Germany diagnoses written in medical records are used for reimbursement, which may influence physicians' documentation behaviour.
Any bias affecting the physicians' documentation would not affect Symptom Score or quality of life, since these clinical outcomes were documented by the patients or caregivers.
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com