Search Results - "DOCUMENTATION"

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Evaluating Nurses' Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis.

Jacques D; Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726., Will J; Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726., Dauterman D; Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726., Zavotsky KE; Department of Nursing, Center for Innovations in the Advancement of Care, NYU Langone Health, New York, NY, United States., Delmore B; Department of Nursing, Center for Innovations in the Advancement of Care, NYU Langone Health, New York, NY, United States., Doty GR; Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726., O'Brien K; Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726., Groom L; Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726.; Department of Population Health, Grossman School of Medicine, New York University, New York, NY, United States.

Journal Article , 2025

Prevalence of Stigmatizing Language in the Triage Documentation of Patients Presenting to the Emergency Department with Pain.

Fung CM; Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan. Electronic address: chfung@med.umich.edu., Kehne A; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan., Macleod C; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan., Logue C; Center for Clinical Management and Research, Ann Arbor VA Hospital, Ann Arbor, Michigan., Lagisetty P; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management and Research, Ann Arbor VA Hospital, Ann Arbor, Michigan.

Journal Article , 2025

An Ethics Consult Documentation Simplification Project: Summation of Participatory Processes, User Perceptions, and Subsequent Use Patterns.

Weaver MS; National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Ave., Washington, DC, 20420, USA. Meaghann.Weaver@va.gov.; Division of Palliative Care, Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA. Meaghann.Weaver@va.gov., Tarzian AJ; National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Ave., Washington, DC, 20420, USA., Hester HN; National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Ave., Washington, DC, 20420, USA., Davidson KR; National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Ave., Washington, DC, 20420, USA., Dismukes RP; National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Ave., Washington, DC, 20420, USA., Foglia MB; National Center for Ethics in Health Care, Veterans Health Administration, 810 Vermont Ave., Washington, DC, 20420, USA.; Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.

Journal Article , 2025

Effects of Repeated Feedback on Pain Documentation: A Cluster Randomized Trial.

Grommi S; Department of Nursing Science, University of Eastern Finland, Kuopio, Finland. Electronic address: sallagro@student.uef.fi., Voutilainen A; Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland., Vaajoki A; Kuopio University Hospital, Kuopio, Finland., Kankkunen P; Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.

Journal Article; Randomized Controlled Trial , 2025

Addressing documentation deficiencies in emergency department records: Implications for fall risk assessment and holistic care in older adults.

Bergström S; Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Geriatrics and Emergency, Mölndal, Sweden. Electronic address: sara.bergstrom@vgregion.se., Rosengren K; Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Geriatrics and Emergency, Mölndal, Sweden; Centre for Person-centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Electronic address: kristina.rosengren@gu.se., Wallengren C; Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Centre for Person-centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Electronic address: catarina.wallengren@gu.se., Schenell R; Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Administration of Eldercare and Welfare, Department of Quality and Development, The City of Gothenburg, Gothenburg, Sweden. Electronic address: ramona.schenell@aldrevardomsorg.goteborg.se., Falk Erhag H; Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden; Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden. Electronic address: hanna.falk@gu.se.

Journal Article , 2025

The Impact of HIRAID Implementation on the Accuracy of Emergency Nurse Documentation in Australian Rural Emergency Departments: A Multicenter Quasi-Experimental Study.

Kennedy B, Lam M, Kourouche S, McCloughen A, Casey L, Curtis K

Journal Article; Multicenter Study , 2025

Diagnosis Documentation Done Right: Cross-Specialty Standard for the Diagnosis Section in German Discharge Summaries - A Mixed-Methods Study.

Frings J; Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany., Rust P; Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany., Meister S; Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.; Department Healthcare, Fraunhofer Institute for Software and Systems Engineering ISST, Dortmund, Germany., Prinz C; Helios University Hospital Wuppertal, Department of Gastroenterology, Witten/Herdecke University, Wuppertal, Germany., Fehring L; Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany. Leonard.Fehring@uni-wh.de.; Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany. Leonard.Fehring@uni-wh.de.; Helios University Hospital Wuppertal, Department of Gastroenterology, Witten/Herdecke University, Wuppertal, Germany. Leonard.Fehring@uni-wh.de.

Journal Article , 2025

Need for User-Friendly Audit Tools: Investigating Dietitians' Use and Requirements of Clinical Documentation Audit Tools.

Schaller F; Division of Nutrition and Dietetics, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.; Adullam-Stiftung Basel, Hospital and Nursing Centres, Basel, Switzerland., Lövestam E; Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden., Jent S; Division of Nutrition and Dietetics, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.

Journal Article , 2025

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Efficiency and Quality of Generative AI-Assisted Radiograph Reporting.

Huang J; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.; Department of Biomedical Engineering, Northwestern University, Evanston, Illinois., Wittbrodt MT; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois., Teague CN; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois., Karl E; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois., Galal G; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois., Thompson M; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois., Chapa A; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois., Chiu ML; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois., Herynk B; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois., Linchangco R; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois., Serhal A; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois., Heller JA; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois., Abboud SF; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois., Etemadi M; Research & Development, Northwestern Medicine Information Services, Chicago, Illinois.; Department of Biomedical Engineering, Northwestern University, Evanston, Illinois.; Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Journal Article , 2025

Modifications to consent documentation with adults with communication disorders following brain injury: An exploratory study.

Watermeyer J, Aylward C

Journal Article , 2025

Improving accurate documentation for reducing restraint use: a quality improvement project in a Dutch academic hospital.

de Boer L; Department of Nursing, Maastricht UMC+, Maastricht, Limburg, Netherlands l.boer@mumc.nl., Scheepers J; Department of Psychiatry, Maastricht UMC+, Maastricht, Netherlands., Vertommen C; Department of Nursing, Maastricht UMC+, Maastricht, Limburg, Netherlands., Klein DO; Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, Limburg, Netherlands., Rietbergen T; Healthcare Evaluation and Appropriate Use, National Health Care Institute, Diemen, Noord-Holland, Netherlands., Bal RA; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands.

Journal Article , 2025

Improving initial vital signs assessment and documentation in the emergency department of regional hospital, Bhutan: quality improvement project.

Wangdi S; Emergency Department, Eastern Regional Referral Hospital, Mongar, Bhutan sherabw1989@gmail.com., Guragai K; Emergency Department, Eastern Regional Referral Hospital, Mongar, Bhutan., Namgay P; Emergency Department, Eastern Regional Referral Hospital, Mongar, Bhutan., Dorji J; Emergency Department, Eastern Regional Referral Hospital, Mongar, Bhutan., Wangchuk K; Emergency Department, Eastern Regional Referral Hospital, Mongar, Bhutan.

Journal Article , 2025

Nurses' understanding of quality documentation: A qualitative study in a Mental Health Institution.

Mabunda NF; Department of Nursing, Faculty of Health Sciences, Sefako Makgatho Health Science University, Pretoria. nkhensani.mabunda@smu.ac.za., Masondo IG, Mokoena-de Beer AG

Journal Article , 2025

Identifying Medication Review Topics to Be Documented in a Structured Form in Electronic Health Record Systems: Delphi Consensus Survey.

Lindholm T; Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland., Lias N; Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland., Kvarnström K; Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.; HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland.; HUS Internal Medicine and Rehabilitation, Helsinki University Hospital, Helsinki, Finland., Holmström AR; Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland., Toivo T; Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.; Hospital Pharmacy, Wellbeing Services County of Pirkanmaa, Tampere University Hospital, Tampere, Finland., Uusitalo M; Innovation and Development Unit, Istekki Ltd, Kuopio, Finland.; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland., Nurmi H; Finnish Medicines Agency Fimea, Helsinki, Finland., Airaksinen M; Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.

Journal Article , 2025

Nursing advocacy and activism: A critical analysis of regulatory documents.

Mainey L; CQUniversity., Richardson S; University of Essex., Essex R; University of Greenwich., Dillard-Wright J; University of Massachusetts Amherst.

Journal Article , 2025

Common errors In medico-legal reporting by the first responders at A tertiary trauma unit In North India.

Mylapalli JL; Forensic Medicine, Division of Forensic Pathology and Molecular DNA, JPN Apex Trauma Centre, All India Institute of Medical Sciences, Raj Nagar, New Delhi, 110029, India. Electronic address: drjhansimylapalli.aiims@gmail.com., Balmuchu G; Forensic Medicine, Department of Forensic Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. Electronic address: govindabalmuchu@gmail.com., Prabhakar V; Forensic Medicine, Division of Forensic Pathology and Molecular DNA, JPN Apex Trauma Centre, All India Institute of Medical Sciences, Raj Nagar, New Delhi, 110029, India. Electronic address: vidhuprabhakar5@gmail.com., Sandhu PR; Forensic Medicine, Division of Forensic Pathology and Molecular DNA, JPN Apex Trauma Centre, All India Institute of Medical Sciences, Raj Nagar, New Delhi, 110029, India. Electronic address: piyush3746@gmail.com., Bodh DP; Forensic Medicine, Division of Forensic Pathology and Molecular DNA, JPN Apex Trauma Centre, All India Institute of Medical Sciences, Raj Nagar, New Delhi, 110029, India. Electronic address: dekibodh93@gmail.com., Madan N; Department of Hospital Administration, All India Institute of Medical Sciences, New Delhi, 110029, India. Electronic address: office.nirupam@gmail.com., Lalwani S; Forensic Medicine, Division of Forensic Pathology and Molecular DNA, JPN Apex Trauma Centre, All India Institute of Medical Sciences, Raj Nagar, New Delhi, 110029, India. Electronic address: drsanjeevlalwani@gmail.com.

Journal Article , 2025

Is AI A-OK? Medicolegal considerations for general practitioners using AI scribes.

Bradfield O; MBBS(Hons), BMedSc(Hons), LLB, MBA, FRACGP, Law and Public Health Unit, Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Mahar P; MBBS (Hons), LLB (Hons), MBA, MDerm, GDLP, PhD, DMedSc, FAICD, FACLM, FACD, Medical Director, Skin Health Institute, Melbourne, Vic; Dermatologist, Department of Dermatology and Burns Unit, Trauma Service, Royal Children@s Hospital Melbourne, Melbourne, Vic; Clinical Associate Professor, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic.

Journal Article , 2025