Background: There has been ample speculation about potential future applications of natural language processing and related technologies for clinical documentation, and yet the mechanics of clinical documentation have changed very little since the passage of the HITECH Act in 2009. Purpose: While awaiting the integration of more advanced technologies into electronic health records (EHRs), we […]

Background: Clinical documentation is challenging when patients are admitted with many diagnoses of varying severity. Documentation of chronic or low-acuity conditions on the History and Physical (H&P) note can feel less salient than primary admission diagnoses. This can lead to under-documentation of comorbid conditions and an underrepresentation of the complexity of care. Capturing this overlooked […]

Background: Accurate documentation of the patient’s diagnoses helps to reflect the severity of illness which has several downstream impacts: clinical outcomes data, risk stratification, hospital quality metrics data such as readmission and mortality index, hospital reimbursement. For this reason, our health system has various ongoing initiatives on clinical documentation to improve the specification of certain […]

Background: It is estimated that 3-5 falls occur per 1000 patient days in the US and UK(1). According to a study looking at National Database of Nursing Quality Indicators (NDNQI), established by the American Nurses Association, 26% of falls result in injury with 1 in 20 causing serious injuries(1). This poses a serious threat to […]

Background: While the electronic health record (EHR) provides many benefits, its use can easily allow for incomplete documentation of relevant historical information. The EHR is designed to store documentation of a patient’s past medical history (PMH), surgical history (PSH), family history (FH), and active hospital problems in the History tab. When the information is in […]

Background: Residents receive little feedback on their clinical reasoning (CR) documentation due to time constraints of supervisors and lack of a shared mental model. We developed an innovative workplace-based assessment tool using machine learning (ML) to provide feedback on CR documentation. Here, we describe the impact of feedback using this assessment tool. Methods: In earlier […]

Background: Appropriate and timely documentation of rapid response events has been shown to have a significant impact on patient care and outcomes. Prior to January 2021, our institution did not have a standardized rapid response note template to facilitate best clinical documentation practices. A review of rapid response events at our institution that occurred during […]

Background: The diagnostic process is dynamic – as additional information becomes available and diagnostic uncertainty is addressed, diagnosis evolves. An accurate and updated problem list in the electronic health record (EHR) should reflect modifications and refinement of the working diagnosis (1). Anecdotally, this does not happen: many providers do not the update problem list or […]

Background: Time spent on electronic medical record (EMR) documentation is one of the top dissatisfiers for providers. With burnout at an all-time high, reducing provider burden while maintaining high quality care is essential to moving healthcare forward in a sustainable way. “While electronic documentation provides a number of benefits as compared to paper-based documentation, including […]

Background: There has been ample speculation about potential future applications of natural language processing and related technologies for clinical documentation, and yet the mechanics of clinical documentation have changed very little since the passage of the HITECH Act in 2009. Purpose: While awaiting the integration of more advanced technologies into electronic health records (EHRs), we […]