Of the 592 records generated from a non-SUD specialty outpatient clinic that had a HEDIS-qualified SUD diagnosis/CPT code combination, 539 (91%) had a progress note on the day of care, of which 338 (63%) were found by chart review to have evidence of SUD treatment.
Of the 700 randomly selected records that met these criteria, 601 (85.9%) had a progress note on the day of care, and 553 (92%) of these were found by chart review to have evidence of SUD treatment.
The records were reviewed for the types of treatment; the progress notes of follow-up appointments (including annual follow-up letters sent by the Department of Medical Informatics) were scrutinized for any documentation of long-term health effects.
When a patient has fallen in the hospital, the physician who is responsible for the patient is informed of the event by medical staff, and the event is recorded in progress notes of EMRs.
In some of the participating hospitals, incident reports were not filed within the medical progress notes of patients, so that staff were unable to review previous reports to find common elements that may be causing ongoing falls for individual patients.
In these cases, we extracted all of the progress notes on the day of interest.
CDA is a document markup standard that specifies the structure and semantics of a clinical document (such as a discharge summary or progress note) for the purpose of exchange.
He is the meticulous type, so meticulous that one of his progress notes on a patient's daily chart was cited by nitpickers in Mount Sinai's records department as the perfect note.
Our results also showed the possibility of application of NLP of progress notes to reduce review time and labor of a manual chart review for detecting adverse events in a hospital.
In addition, charts were examined for the following: any written acknowledgement of the positive IPV screen (whether on the faxed back response form or in the progress note), documentation of referral, safety planning and detailed descriptive circumstances of the abuse.
