Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic
S Mulvehill, G Schneider, CM Cullen… - The Journal of the …, 2005 - Am Board Family Med
Purpose: To compare a template-driven medical documentation system to undirected
handwritten documentation and determine whether the template (1) decreases physician …
handwritten documentation and determine whether the template (1) decreases physician …
Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department
KA Marill, ES Gauharou, BK Nelson… - Annals of emergency …, 1999 - Elsevier
Study objective: To determine whether use of the T-System (Emergency Services
Consultants, Irving, TX) template-generated medical documentation system (1) decreases …
Consultants, Irving, TX) template-generated medical documentation system (1) decreases …
Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians
Objective: Computerized physician documentation (CPD) has been implemented throughout
the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace …
the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace …
Comparison of handheld computer-assisted and conventional paper chart documentation of medical records: a randomized, controlled trial
D Stengel, K Bauwens, M Walter, T Köpfer… - JBJS, 2004 - journals.lww.com
Background: Daily documentation and maintenance of medical record quality is a crucial
issue in orthopaedic surgery. The purpose of the present study was to determine whether …
issue in orthopaedic surgery. The purpose of the present study was to determine whether …
Improving physician documentation through a clinical documentation management program
TA Hicks, CA Gentleman - Nursing administration quarterly, 2003 - journals.lww.com
Improving physician documentation ensures that the patient's clinical course is clearly
recorded. North Carolina Baptist Hospital implemented interventions addressing physician …
recorded. North Carolina Baptist Hospital implemented interventions addressing physician …
Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians
T Kuhn, P Basch, M Barr, T Yackel… - Annals of internal …, 2015 - acpjournals.org
Clinical documentation was developed to track a patient's condition and communicate the
author's actions and thoughts to other members of the care team. Over time, other …
author's actions and thoughts to other members of the care team. Over time, other …
Implications of clinical documentation (in) accuracy: a pilot study among general surgery residents
Accurate and reliable medical records are necessary for assessing, improving, and
reimbursing healthcare services. Clear and concise physician documentation is essential to …
reimbursing healthcare services. Clear and concise physician documentation is essential to …
The use of evidence-based, problem-oriented templates as a clinical decision support in an inpatient electronic health record system
R Mehta, NS Radhakrishnan… - Applied clinical …, 2016 - thieme-connect.com
The integration of clinical decision support (CDS) in documentation practices remains
limited due to obstacles in provider workflows and design restrictions in electronic health …
limited due to obstacles in provider workflows and design restrictions in electronic health …
Clinical documentation: composition or synthesis?
L Mamykina, DK Vawdrey, PD Stetson… - Journal of the …, 2012 - academic.oup.com
Objective To understand the nature of emerging electronic documentation practices,
disconnects between documentation workflows and computing systems designed to support …
disconnects between documentation workflows and computing systems designed to support …
Deciphering the physician note
Objective information about legibility of physician handwriting is scant. This retrospective
chart review compared handwritten general medicine clinic chart notes from internal …
chart review compared handwritten general medicine clinic chart notes from internal …