Objective: This study aimed to review the association between timeliness to completion of a discharge summary to 30-day readmission to the hospital. Methods: This was a retrospective chart review of 109 patients discharged from Mayo Clinic Hospital. Results: Twenty-four of these patients were readmitted within 30 days. The time to…
Purpose: To evaluate physician utilization of speech recognition technology (SRT) for medical documentation in two hospitals. Methods: A quantitative survey was used to collect data in the areas of practice, electronic equipment used for documentation, documentation created after providing care, and overall thoughts about and satisfaction with the SRT. The…
Objectives: Accurate and consistent documentation of pain management, including patient responses regarding improvement in pain scores, is essential for improving patient care. The objective of the project was to evaluate the current prescribing patterns and to review the current documentation for opioid-managed, chronic pain patients in an academic continuity of…
Objective: To perform a needs assessment to determine the extent to which hospitalist providers recognize and intervene upon obese patients in the hospital setting. Methods: A chart review was performed for patients admitted to the hospitalist service at Johns Hopkins Bayview Medical Center between September 1 and October 1, 2008….
Abstract:Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma…
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