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medical chart documentation

Notes: - in 2019, physicians in the U.S. spent ~125,000,000 hours outside office hours completing medical documentation [1]

Related

medical record

Specific

alarm systems assessed, GERD anemia plan of care documented, ESRD antibiotic neither prescribed nor dispensed, URI/PHAR/A-BRONCH antihistamines/decongestants neither prescribed nor recommended, OME AREDS formulation prescribed or recommended assessment of coronary artery disease assessment of pneumococcus immunization status auricular or periauricular pain assessed, AOE barium swallow not ordered clinical genetics documentation colonoscopy report dashboard; relative value units (RVUs) discharge summary documentation for back pain documentation for epilepsy documentation for major depressive disorder documentation for melanoma documentation for palliative care documentation of advance directives documentation of atrial fibrillation, STR documentation of bone scan for prostate cancer documentation of falls in the elderly documentation of fracture in osteoporosis documentation of hearing test within 6 months prior to tympanostomy documentation of iron stores prior to initiating erythropoietin therapy documentation of labs for chronic renal failure documentation of mental health assessment prior to intervention, BkP documentation of PSA/staging/Gleason score for prostate cancer documentation of treatment for nephropathy dyspnea not screened, Pall Cr GI & renal risk factors assessed for OA patients prescribed NSAIDs glaucoma plan of care documented glucorticoid management plan documented, RA heart failure assessed, CAD/HF hemoglobin oxygen saturation < 88% hydration status assessed, CAP hydration status documented, dehydrated hydration status documented, normally hydrated hypertension plan of care documentation imaging documentation, BkP immunity to hepatitis A immunity to hepatitis B interval of >= 3 years since last colonoscopy ischemic stroke symptom onset < 3 hours prior to arrival ischemic stroke symptom onset >= 3 hours prior to arrival low risk for retinopathy, DM medical chart documentation for dementia medical chart documentation, atrial fibrillation/atrial flutter medical chart documentation, GERD medical chart documentation, hepatitis C medical chart documentation, RhD negative medical chart documentation, RhD positive medical chart documentation, rheumatoid arthritis pain severity assessed, ONC patient not receiving erythropoiesis-stimulating agent, CKD patient not receiving erythropoietin therapy, HEM preoperative documentation for cataracts surgery prostate cancer risk of recurrence suicide risk assessed, MDD systemic antimicrobial therapy not prescribed, AOE systemic corticosteroids not prescribed, OME thromboembolic risk factors assessed for atrial fibrillation urinary incontinence characterized urinary incontinence plan of care documented

General

clinical procedure

References

  1. Gaffney A et al. Medical documentation burden among US office-based physicians in 2019: A national study. JAMA Intern Med. 2022 Mar 28:e220372 PMID: 35344006 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2790396