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Meeting
Search Results for Documentation
Abstract Number: 125
Hospital Medicine 2016, March 6-9, San Diego, Calif.
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 […]
Abstract Number: 128
SHM Converge 2021
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 […]
Abstract Number: 162
SHM Converge 2021
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 […]
Abstract Number: 175
Hospital Medicine 2020, Virtual Competition
Background: Central line-associated bloodstream infection (CLABSI) is a morbid and potentially lethal complication. National policies related to CLABSI mandate public reporting of this adverse event, with hospitals receiving penalties based on their CLABSI rates. Contemporary data suggest that peripherally inserted central catheters (PICCs) placed outside critical care settings are a large contributor to hospital CLABSI […]
Abstract Number: 186
Hospital Medicine 2018; April 8-11; Orlando, Fla.
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 […]
Abstract Number: 191
Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.
Background: The advent of the Electronic Health Record (EHR) has changed the face of medical documentation. Illegibility and absence of data have all but disappeared, and EHRs can foster thoughtful assessments by providing a platform to craft differential diagnoses. However, EHRs have also introduced features like “copy and paste” and “blow in” templates that can […]
Abstract Number: 202
Hospital Medicine 2016, March 6-9, San Diego, Calif.
Background: The observation unit is frequently a destination for patients with yet undifferentiated conditions. The goal of the observation stay is to complete a crucial diagnostic test or treatment trial that should help specify the diagnosis, but that is not always the case. Understanding the frequency of diagnoses that remain unspecified after an observation visit […]
Abstract Number: 206
Hospital Medicine 2016, March 6-9, San Diego, Calif.
Background: Patient pass-offs represent a known vulnerability in patient care. The Hospital Medicine Unit at Massachusetts General Hospital has several specialized roles including an admitting hospitalist, a rounding hospitalist, and a nocturnist. Our on-service time is typically four or five days in a row. Our hospitalists and nocturnists work in six hour, ten hour and […]
Abstract Number: 209
Hospital Medicine 2016, March 6-9, San Diego, Calif.
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 […]
Abstract Number: 219
Hospital Medicine 2019, March 24-27, National Harbor, Md.
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 […]