Background: Physicians spend more time on documentation and less on direct patient care. Burnout and career disengagement have been linked to time spent documenting in the electronic health record. A scribe program could reduce the documentation burden on hospitalists, increase revenue capture and improve the efficiency of the admission process. Purpose: We implemented a prospective [...]

Background: High quality clinical documentation is essential for patient safety. Thoughtful clinical documentation transmits one’s clinical reasoning and is considered to be a professional responsibility. There are no accepted standards for assessing documentation with respect to clinical reasoning. We therefore undertook this study to establish a metric to evaluate hospitalists’ documentation of clinical reasoning in [...]

Background: Hospital discharge is a complex and dangerous process. The emergence and rapid growth of the Hospitalist specialty with the simultaneous decline of traditional practice models complicates discharges. In light of the discontinuity, it is crucial to build reliable communication tools that facilitate transmission of critical information.The discharge summary is an essential piece of that [...]