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We did not record the rate of documentation per provider.
We found an extremely high rate of documentation error.
Several possible factors could have contributed to our findings of a low rate of documentation of communication abilities.
While this could account for the low rate of documentation, there were a large number of encounter notes and quite a low rate across the notes.
RBR users found it helpful for many purposes, and had a consistently high rate of documentation of many aspects of well-baby care.
The low rate of documentation is in agreement with studies that examined CKD documentation using billing codes rather than the EHR problem list.
Similar(51)
This observational study found an unusually low incidence of documented delirium that is mostly likely attributable to low rates of documentation of diagnosed delirium or a low incidence of delirium diagnosis due to improper screening.
Patients without a documented history of CVD or diabetes had strikingly more dissimilar rates of documentation and control between weight categories than patients with CVD or diabetes.
However, little is known about the quality of hypertension management in family medicine resident clinics.To examine rates of documentation and treatment of elevated blood pressure, and to identify missed opportunities to address hypertension.
This study found extremely high rates of documentation errors and this should be the area of greatest priority for intervention.
Despite the presence of an electronic medical record designed to facilitate documentation, rates of documentation for drug allergy and smoking status fell below desirable levels.
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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