Medical Record Documentation System in Ethiopia

Clinical Documentation in Emergency Departments : Integrating paper - based documentation into the electronic medical record

Medical Record Documentation Among Interns: A Prospective Quality Improvement Study.

Comprehensive record keeping is a key aspect of medical practice. The National Hospitals Office (NHO) and Irish Medical Council (IMC) have published guidelines in this area. A prospective audit of 100 patients assessed by interns was performed to quantify adherence with these guidelines followed by an educational session and email reminders. Adherence was reassessed in an incidental manner. Com...

The Effect of Feedback and Incentive Mechanisms on Improving Residents’ Medical Record Documentation Procedure

Introduction: Studies indicate that using behavior changing interventions may improve medical record documentation. This study aimed to examine the effect of feedback and incentive mechanisms on medical record documentation among surgery residents in Kashan University of Medical Sciences. Methods: This quasi-experimental study examined the effect of feedback and incentive mechanisms on 19 surge...

Impact of a New Medical Record System for Emergency Departments Designed to Accelerate Clinical Documentation

Recording information in emergency departments (EDs) constitutes a major obstacle to efficient treatment. A new electronic medical records (EMR) system focusing on clinical documentation was developed to accelerate patient flow. The aim of this study was to examine the impact of a new EMR system on ED length of stay and physician satisfaction. We integrated a new EMR system at a hospital alread...

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

INTRODUCTION Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determ...