Background: Our single academic medical center implemented a standardized Outside Hospital (OSH) communication process, encouraging physician completion of a dedicated templated patient transfer note for admission to any Department of Medicine (DOM) specialty. Prior outcomes analysis revealed that documentation with any transfer note, templated or non-templated, is significantly associated with improved outcomes of death within [...]

Background: Outside hospital (OSH) transfer processes vary across institutions. The fragmented and complex nature of OSH transfers pose patient safety risks. A recent implementation of a standardized OSH transfer process with templated note for hospital medicine patients at our institution demonstrated promising patient safety outcomes and a significant increase in physician satisfaction. This pilot study [...]

Background: With the broad implementation of electronic health records, clinical documentation integrity continues to be under increasing scrutiny. On average, physicians spend over a third of their time documenting patient data¹; this burden has been extensively correlated to burnout². Leveraging automated note templates with integrated safety rounding checklists, we attempted to standardize more efficient documentation [...]

Background: On January 1st, 2023, the AMA released updated CPT E&M codes and guidelines. While there were welcome aspects to these changes – including removing need for an extensive physical exam and making it easier to capture prolonged service time – healthcare systems were left grappling with a need to quickly respond to these complex [...]

Background: Addiction medicine services are a critical component of care for patients suffering from opioid use disorder. Previous research has indicated that opioid use disorder patients have higher lengths of stay (LOS) and higher hospital readmission rates than patients admitted for a different medical condition. Even though the presence of a specialized team of addiction [...]

Background: Electronic medical record (EMR) chart notes are primary tool through which providers communicate their thought processes, clinical decision making and care plans. Our health system consists of 11 hospitals ranging from large academic medical center to small hospitals in Minnesota and Western Wisconsin. Hospital Medicine team represent over 250 providers across all the sites. [...]