Background: Diagnostic errors (DE) – defined as incorrect, missed, or delayed diagnoses not made within a timeframe consistent with standard clinical practice – are common and can lead to harm, especially in acute care settings. One cause of DEs is suboptimal clinical reasoning in the diagnostic process. Electronic clinical documentation has been suggested to potentially [...]

Background: Accurate clinical documentation is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. However, since coding rules and terminology differ from common clinical language, there is a risk that the clinical reality will get lost in translation. This is where clinical documentation improvement (CDI) programs come [...]

Background: Moonlighting trainees are an essential labor source for expanding hospital medicine groups. Though the ACGME specifies moonlighting eligibility criteria and duty work hour restrictions, it does not address specific onboarding requirements. Prior to this project, our section of hospital medicine had no formal onboarding process for moonlighters despite 400-500 shifts covered annually by approximately [...]

Background: ~ 1 in 10 patients has a penicillin allergy listed, but up to 90% of those patients may tolerate penicillins and/or cephalosporins. This inaccurate history and documentation leads to altered clinical decision making and the use of 2nd or 3rd line antibiotics, and can lead to adverse short and long term outcomes at both [...]

Background: Hospitalist providers are the backbone of inpatient medicine and are the ideal audience for hospital-driven metrics given their direct and constant care of hospitalized patients. However, these metrics often seem ambiguous, resulting in frustration and dismissal. Guiding hospitalist providers through less commonly understood topics such as utilization review determinations (nuances of observation/inpatient status), high [...]