Author Archives: Julie Clements
Avoiding Transcription Errors in Medication Administration
Transcribing a medication order or the transfer of information from an order sheet to nursing documentation is a crucial step in medication administration. With accurate transcription, the other steps in medication administration such as dispensing the drug and delivering the … Continue reading
Read MoreDocumenting Physician-Patient Encounters Vital to Diagnose and Treat Chronic Migraine
According to a new study presented at the 57th Annual Scientific Meeting of the American Headache Society, migraines may be underreported and under-treated in teen athletes. In most cases studied, it is unclear whether there occurred an exacerbation of primary … Continue reading
Read MoreStudy: Significant Lag Times Exist between Evaluating and Documenting Patient Pain Scores
When it comes to nursing transcription, frequent documentation of pain scores is very important for proper pain assessment and treatment. However, the study findings presented at the American Medical Informatics Association’s 2014 annual symposium highlight a significant delay on the … Continue reading
Read MoreSurgical Errors on the Rise, Keep Your Operative Reports Accurate
A new state report covering Connecticut hospitals found that the number of adverse events in hospitals and other healthcare facilities reached 500 in 2013 i.e. double the number of 244 incidents reported in 2012. When it comes to surgical adverse … Continue reading
Read MoreNLP to Ensure Quality of Colonoscopy
A new study by a group of researchers from the Regenstrief Institute and the Indiana University School of Medicine shows that natural language processing or NLP accurately tracks colonoscopy quality. The presence of adenomas in the colon predicts the patient’s … Continue reading
Read MoreTransformation of Medical Transcription Openings
Medical transcription – a task which every healthcare institution is burdened with, and is therefore outsourced en masse, is probably heading in another direction, that of increasing automation. It would probably come as a revelation that the years from 2007 … Continue reading
Read MoreAcrostic for Quality Pediatric Post-take Ward Rounds Documentation
It is very important to maintain quality and accuracy when documenting pediatric post-take ward rounds (PTWR) since care is evaluated, and coordinated care plans are formulated during this time. This documentation task often left to junior doctors is quite challenging … Continue reading
Read MoreCyber Attacks on the Rise, Improve your Electronic Data Security
A survey published by IDC Health Insights in November 2014 found that healthcare organizations are now more prone to cyber attacks than ever before, partly owing to the widespread use of electronic clinical documentation. Cyber criminals can access your digital … Continue reading
Read MorePDCA Quality Principles for Clinical Documentation
As the healthcare system in the U.S is shifting from paper-based to electronic health records (EHRs), it has become very important to focus on the quality of patients’ records for improved and consistent patient safety outcomes. This has made the … Continue reading
Read MoreQuality Assurance for Health Care Documentation
Quality in health care documentation is crucial when it comes to ensuring proper and timely health care. In view of this, the Association for Healthcare Documentation Integrity (AHDI) has paid down best practices to assure quality, timeliness and security in … Continue reading
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