It’s Time to Wikify Clinical Documentation

Real-time tablet-based resuscitation documentation by the team leader: evaluating documentation quality and clinical performance

BACKGROUND Precise and complete documentation of in-hospital cardiopulmonary resuscitations is important but data quality can be poor. In the present study, we investigated the effect of a tablet-based application for real-time resuscitation documentation used by the emergency team leader on documentation quality and clinical performance of the emergency team. METHODS Senior anaesthesiologist...

Use of electronic clinical documentation: time spent and team interactions

OBJECTIVE To measure the time spent authoring and viewing documentation and to study patterns of usage in healthcare practice. DESIGN Audit logs for an electronic health record were used to calculate rates, and social network analysis was applied to ascertain usage patterns. Subjects comprised all care providers at an urban academic medical center who authored or viewed electronic documentati...

Interpreting nurses' responses to clinical documentation alerts.

OBJECTIVE To understand how nurses respond to alerts that detect attempts to enter into electronic health records patient weights that vary significantly from previously recorded weights. METHODS Examination of subsequent patient weights to determine if the alerts were true positive (TP) or false positive (FP), and whether nurses overrode alerts, changed their entry or quit without storing a ...

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