Sentence examples for visit documentation from inspiring English sources
The CTN sites therefore separate subjects' research and clinic records, with study visit documentation residing in the research record.
Thus, for Advanced HIT, entry of diagnostic codes was a proxy for completed visit documentation.
This concurs with the literature on improved well-baby visit documentation with structured forms.
Outcome measures were well-baby visit documentation of growth, nutrition, safety issues, developmental milestones, physical examination, and overall comprehensiveness.
Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors was poor (Table 6).
No associations between clinic characteristics (size, place) or family practitioner qualification and ED visit documentation was found.
Overall, the fields with the highest level of completeness were for visit documentations and prescriptions (>70 %).
The average time required to complete a scribe visit (including documentation) was 37% shorter than that needed for a control visit.
The screening visit included documentation of the medical history and concomitant medication, an extensive medical examination including 12-lead electrocardiogram, lung function and allergy testing, a drug screening, and a pregnancy test for female subjects.
Despite the recording of weight at nearly every visit, only documentation of "obesity" or a synonym such as "over-weight" or "high BMI" in a clinician's note or a recommendation for dietary modification, weight loss, referral to a dietician, weight reduction program or prescribing a weight reduction medication was considered recognition of obesity.
In most medical centers, once Advanced HIT was implemented for 80 90% of patient visits in the office setting, 99 100% of visits had documentation complete by the same day.
