Background: One target for improvement of effective patient centered care on the inpatient medical ward is the mechanism for communication among the multidisciplinary care team (MCT).  The medical service at Stanford Hospital and Clinics recently implemented morning “team care rounds” (TCRs) that provided space for the MCT members, including the physician (MD), nurse (RN), case [...]

Background: The daily progress note is the foundation of inpatient documentation and communication for healthcare providers. With the advent of the electronic medical record, copy-and-pasting, note bloat, inconsistencies, erroneous data, and lack of cognitive processing have become widespread leading to difficult to read and inaccurate progress notes.  Purpose: At Bassett Medical Center, it was determined [...]

Background: New York State has identified a list of controlled medications that require frequent monitoring and review. New York State law dictates that these medications, when disbursed in a hospital setting, must be reviewed and re-ordered on a weekly basis. In order to maintain compliance with New York State law, the Electronic Medical Record (EMR) [...]

Background: Outside Medical Records are essential for accurate continuity of care when patients are transferred from one healthcare system to another. Despite their importance, obtaining records in a timely manner is a notoriously difficult process. At Stanford Hospital, the medicine teams were burdened with 5 pages of paperwork per record request for a single patient. [...]

Background: Discharge checklists may reduce medical errors. Traditional paper checklists do not fit into the current workflow in centers that utilize electronic medical records (EMRs). In an era where team-based care is becoming widespread, defining each person’s role in discharge practices is increasingly important.  Methods: Our aim was to develop and implement a standardized discharge [...]

Background: Accurate problem lists linked to electronic medical record (EMR) clinical data can be useful for chart review by clinicians for patient care, clinical decision support design, and data extraction for clinical research.  The EMR at Stanford Hospital allows the problem list to be modified in several ways: adding and deleting problems, and designating problems [...]