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: 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: 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: Stigmatizing language in clinical notes can negatively impact physician attitudes, propagate bias, affect prescribing behaviors, and exacerbate healthcare disparities, yet remains prevalent even in the Open Notes era. Prior analyses of stigmatizing terms in clinical notes are limited by the lack of context in which terms are used and multiple meanings of certain words [...]

Background: Accurate and timely documentation is essential for patient care, as well as the appropriate reflection of patient complexity and severity of illness. Most hospitals utilize a traditional retrospective or contemporaneous physician-query strategy to ensure documentation accurately impacts performance data, reputation/ranking, and reimbursement.  Purpose: Here, we highlight three unique, hospitalist-driven interventions to support accurate documentation [...]

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: 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: 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: The original goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the provider’s thought processes.  Electronic health records (EHRs) allow physicians to supplement traditional manual data entry with copied or imported text in these notes. However, this increases the risk of including outdated, inaccurate, or unnecessary information, [...]

Background: A problem list serves as a central place for hospital-based clinicians to obtain a comprehensive and concise view of the patient’s active medical conditions. Use of the hospital problem list has many potential benefits: it provides a mental model of patient’s health status; streamlines the documentation process; makes chart review more efficient; facilitates communication [...]