Background: Recent widespread adoption of electronic health records (EHRs) has dramatically increased the amount of information quickly accessible to clinicians. Given recent pushes for interoperability and consumer generated data in EHRs, the volume of information will continue to grow. The result is clinicians who experience information overload and lack the time and ability to comprehensively [...]

Background: Recent widespread adoption of electronic health records (EHRs) has dramatically increased the amount of information quickly accessible to clinicians. Given recent pushes for interoperability and consumer generated data in EHRs, the volume of information will continue to grow. The result is clinicians who experience information overload and lack the time and ability to comprehensively [...]

Background: Internal medicine residents face multiple barriers to participating in and documenting goals of care (GOC) meetings in the intensive care unit (ICU). Barriers include heavy workloads, need for urgent stabilization of critically ill patients, and inadequate communication skills training. Guidelines recommend regularly conducting and documenting GOC meetings for critically ill patients, to facilitate communication [...]

Background: Clinical Documentation Improvement programs have been present in adult hospitals for many years. These programs strive to promote clinicians working together with nurse specialists to appropriately depict the care delivered and increase coding accuracy. This collaboration has traditionally been through written and verbal documentation queries that clarify diagnoses based on a patient’s clinical indicators [...]

Background: Mortality is the first quality metric reported by CMS, and historically a key measure for evidence based medicine since the 1800’s. THINK:  John Snow removing the handle from the Broad street well pump to reduce cholera deaths  Ignaz Semmelweis demonstrating washing hands reduced puerperal fever and death. Mortality rates are risk adjusted [...]

Background: Since the advent of Electronic Health Record(EHR) and subsequent workload of clinical documentation, Hospital Medicine physicians are finding themselves spending more time in front of the computer and less with their patients. The implementation of EHR was intended to help physicians improve productivity and quality, however, data shows we are spending up to 25% [...]

Background: Hospitalists have an increasing role in caring for patients with advanced illness. Due to time constraints, lack of experience and the sensitivity of the topic, it is challenging for Hospitalists to engage in adequate conversations regarding advanced care planning. Moreover, when these conversations do occur, documentation of Advanced Directives and Code Status is frequently [...]

Background: Electronic health record (EHR) systems are used by a majority of US hospitals. EHR use has been associated with increased task complexity, clinical data volume and provider documentation demands. Studies of multiple specialties suggest that a significant amount of provider time is spent on indirect patient care activities including turbulent provider workflows and documentation. [...]

Background: Patient record form one of the most important part of clinical care as the primary source for patient information for primary team, consultants, nurses and other paramedic staff and help in providing a higher quality of care, as well as monitoring patient safety. Incomplete patient records are a source of gaps in patient care [...]