Clinical documentation: composition or synthesis?

Clinical documentation: composition or synthesis?

OBJECTIVE To understand the nature of emerging electronic documentation practices, disconnects between documentation workflows and computing systems designed to support them, and ways to improve the design of electronic documentation systems. MATERIALS AND METHODS Time-and-motion study of resident physicians' note-writing practices using a commercial electronic health record system that inclu...

Clinical documentation standards--promise or peril?

Imagine a future of integrated clinical information systems that transcend the physical boundaries of clinical units, institutions and community care, providing nurses with comprehensive access to information and knowledge to support the delivery of care to individuals and families. Imagine not having to gather the same information repeatedly, ask the same questions over and over again, or stru...

Clinical documentation manual audit

Introduction Preliminary audit studies in HA (Hospital Authority) hospitals have shown that diagnosis and procedure data reported in the electronic records were very accurate. However, appropriateness is as important as accuracy in clinical documentation. With the introduction of internal resource allocation based on Casemix Pay for Performance (P4P), the relevance of clinical documentation bec...

Clinical Trials Simulation System Documentation

Xive® implant system – Clinical documentation