Search Results - "documentation"

A Multiphase Quality Improvement Project to Increase Relative Value Unit Generation Through Documentation Practices in a Pediatric Emergency Department.

Authors: Fairchild VC Powers E Siew L et al.

Source: Pediatric emergency care [Pediatr Emerg Care] 2025 Oct 01; Vol. 41 (10), pp. 816-822. Date of Electronic Publication: 2025 Jul 15.

Publication Type: Journal Article

Journal Info: Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 8507560 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1535-1815 (Electronic) Linking ISSN: 07495161 NLM ISO Abbreviation: Pediatr Emerg Care Subsets: MEDLINE

MeSH Terms: Emergency Service, Hospital*/organization & administration , Emergency Service, Hospital*/economics , Emergency Service, Hospital*/standards , Quality Improvement*/organization & administration , Documentation*/standards , Documentation*/methods , Relative Value Scales*, Humans ; Length of Stay/statistics & numerical data ; Child ; Hospitals, Pediatric

Evidence-based Practice: Updating Contingency Paper Documentation.

Authors: Crumley Aybar B Maheu N

Source: Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses [J Perianesth Nurs] 2025 Oct; Vol. 40 (5), pp. 1088-1096. Date of Electronic Publication: 2025 Mar 12.

Publication Type: Journal Article; Practice Guideline

Journal Info: Publisher: W.B. Saunders Company Country of Publication: United States NLM ID: 9610507 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1532-8473 (Electronic) Linking ISSN: 10899472 NLM ISO Abbreviation: J Perianesth Nurs Subsets: MEDLINE

MeSH Terms: Documentation*/standards , Documentation*/methods , Evidence-Based Practice* , Postanesthesia Nursing*, Humans ; Review Literature as Topic

Examining Seizure Documentation Practices by Primary Care Clinicians.

Authors: Jacobs A Chiofalo J Shuman S et al.

Source: Journal of the American Board of Family Medicine : JABFM [J Am Board Fam Med] 2025 Nov 24; Vol. 38 (4), pp. 735-739. Date of Electronic Publication: 2025 Nov 24.

Publication Type: Journal Article; Observational Study

Journal Info: Publisher: American Board of Family Medicine Country of Publication: United States NLM ID: 101256526 Publication Model: Electronic Cited Medium: Internet ISSN: 1558-7118 (Electronic) Linking ISSN: 15572625 NLM ISO Abbreviation: J Am Board Fam Med Subsets: MEDLINE

MeSH Terms: Documentation*/statistics & numerical data , Documentation*/standards , Primary Health Care*/statistics & numerical data , Primary Health Care*/standards , Seizures*/therapy , Seizures*/diagnosis , Physicians, Primary Care*/statistics & numerical data , Physicians, Primary Care*/standards , Practice Patterns, Physicians'*/statistics & numerical data, Humans ; Retrospective Studies ; Male ; Female ; Middle Aged ; Adult ; Electronic Health Records/statistics & numerical data ; Referral and Consultation/statistics & numerical data ; Aged

The Great Scribe-Off: A Comparative Analysis of AI Scribes Versus Human Documentation in Simulated General Practice Consultations.

Authors: Foo D Tan J Hansra A et al.

Source: Studies in health technology and informatics [Stud Health Technol Inform] 2025 Nov 12; Vol. 333, pp. 34-39.

Publication Type: Journal Article; Comparative Study

Journal Info: Publisher: IOS Press Country of Publication: Netherlands NLM ID: 9214582 Publication Model: Print Cited Medium: Internet ISSN: 1879-8365 (Electronic) Linking ISSN: 09269630 NLM ISO Abbreviation: Stud Health Technol Inform Subsets: MEDLINE

MeSH Terms: Documentation*/methods , Documentation*/standards , General Practice* , Artificial Intelligence* , Electronic Health Records*, Humans ; Australia

Investigating the frequency of unreported cases and laboratory correspondence practices for variants of uncertain significance in pediatric epilepsy.

Authors: Vilaboy T Wong K Tristani-Firouzi M et al.

Source: Epilepsia open [Epilepsia Open] 2025 Oct; Vol. 10 (5), pp. 1726-1732. Date of Electronic Publication: 2025 Aug 26.

Publication Type: Journal Article

Journal Info: Publisher: John Wiley & Sons, Inc Country of Publication: United States NLM ID: 101692036 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 2470-9239 (Electronic) Linking ISSN: 24709239 NLM ISO Abbreviation: Epilepsia Open Subsets: MEDLINE

MeSH Terms: Epilepsy*/diagnosis , Epilepsy*/genetics , Genetic Testing*/standards , Genetic Testing*/statistics & numerical data , Documentation*/standards , Documentation*/statistics & numerical data , Laboratories, Clinical*/standards , Laboratories, Clinical*/statistics & numerical data , Practice Patterns, Physicians'*/statistics & numerical data, Retrospective Studies ; Humans ; Male ; Female ; Child ; Genetic Variation/genetics ; Correspondence as Topic ; Practice Guidelines as Topic

Evaluating the Efficacy of Large Language Models in Generating Medical Documentation: A Comparative Study of ChatGPT-4, ChatGPT-4o, and Claude.

Authors: Lim B Seth I Maxwell M et al.

Source: Aesthetic plastic surgery [Aesthetic Plast Surg] 2025 Oct; Vol. 49 (20), pp. 5846-5857. Date of Electronic Publication: 2025 Apr 14.

Publication Type: Journal Article; Comparative Study; Evaluation Study

Journal Info: Publisher: Springer-Verlag Country of Publication: United States NLM ID: 7701756 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1432-5241 (Electronic) Linking ISSN: 0364216X NLM ISO Abbreviation: Aesthetic Plast Surg Subsets: MEDLINE

MeSH Terms: Documentation*/methods , Documentation*/standards , Language* , Surgery, Plastic* , Electronic Health Records*, Humans ; Reproducibility of Results ; Comprehension ; Large Language Models ; Generative Artificial Intelligence

Challenges in data documentation and retrieval in the ASHA diary from a usability perspective.

Authors: Patel S Tandon P

Source: Social science & medicine (1982) [Soc Sci Med] 2025 Oct; Vol. 382, pp. 118370. Date of Electronic Publication: 2025 Jul 03.

Publication Type: Journal Article

Journal Info: Publisher: Pergamon Country of Publication: England NLM ID: 8303205 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1873-5347 (Electronic) Linking ISSN: 02779536 NLM ISO Abbreviation: Soc Sci Med Subsets: MEDLINE

MeSH Terms: Documentation*/standards , Documentation*/methods , Diaries as Topic* , Information Storage and Retrieval*/methods , Information Storage and Retrieval*/standards, Humans ; Female ; Qualitative Research ; Adult ; Male ; India ; Surveys and Questionnaires ; Middle Aged

Cancer stage documentation and accuracy: Single-center retrospective study on oropharyngeal cancers.

Authors: Baran E Lee M Kamalraj P et al.

Source: Oral oncology [Oral Oncol] 2025 Dec; Vol. 171, pp. 107795. Date of Electronic Publication: 2025 Nov 25.

Publication Type: Journal Article

Journal Info: Publisher: Elsevier Country of Publication: England NLM ID: 9709118 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1879-0593 (Electronic) Linking ISSN: 13688375 NLM ISO Abbreviation: Oral Oncol Subsets: MEDLINE

MeSH Terms: Oropharyngeal Neoplasms*/pathology , Electronic Health Records* , Documentation*/standards, Humans ; Retrospective Studies ; Female ; Male ; Neoplasm Staging ; Middle Aged ; Aged ; Adult ; Aged, 80 and over

Implementation of Advanced Care Planning Standardized Documentation and Billing in the Emergency Department: A Retrospective Cohort Study.

Authors: Westlake E Cash A Ragan J et al.

Source: The Journal of emergency medicine [J Emerg Med] 2025 Dec; Vol. 79, pp. 520-528. Date of Electronic Publication: 2025 Sep 11.

Publication Type: Journal Article

Journal Info: Publisher: Elsevier Country of Publication: United States NLM ID: 8412174 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 0736-4679 (Print) Linking ISSN: 07364679 NLM ISO Abbreviation: J Emerg Med Subsets: MEDLINE

MeSH Terms: Documentation*/standards , Documentation*/methods , Documentation*/statistics & numerical data , Advance Care Planning*/standards , Advance Care Planning*/statistics & numerical data, Humans ; Retrospective Studies ; Emergency Service, Hospital/organization & administration ; Emergency Service, Hospital/statistics & numerical data ; Female ; Male ; Aged ; Middle Aged ; Aged, 80 and over ; Cohort Studies ; Quality Improvement ; Electronic Health Records

Efficient computer vision pipeline for automated anesthetic injection documentation.

Authors: Nissan A Mahameed F Gershov S et al.

Source: Computer assisted surgery (Abingdon, England) [Comput Assist Surg (Abingdon)] 2025 Dec; Vol. 30 (1), pp. 2582020. Date of Electronic Publication: 2025 Oct 29.

Publication Type: Journal Article

Journal Info: Publisher: Taylor & Francis Country of Publication: England NLM ID: 101681550 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 2469-9322 (Electronic) Linking ISSN: 24699322 NLM ISO Abbreviation: Comput Assist Surg (Abingdon) Subsets: MEDLINE

MeSH Terms: Documentation*/methods , Anesthetics*/administration & dosage , Injections*, Humans ; Syringes ; Operating Rooms ; Reproducibility of Results

Improved energy goal documentation in pediatric intensive care unit with standardized electronic health records: A quality improvement initiative.

Authors: Vendiola DF Pan AY Andres J et al.

Source: Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition [Nutr Clin Pract] 2025 Dec; Vol. 40 (6), pp. 1629-1637. Date of Electronic Publication: 2025 Sep 24.

Publication Type: Journal Article

Journal Info: Publisher: Wiley Country of Publication: United States NLM ID: 8606733 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1941-2452 (Electronic) Linking ISSN: 08845336 NLM ISO Abbreviation: Nutr Clin Pract Subsets: MEDLINE

MeSH Terms: Electronic Health Records*/standards , Quality Improvement* , Intensive Care Units, Pediatric*/standards , Documentation*/standards , Documentation*/methods , Energy Intake* , Critical Care*/standards , Critical Care*/methods , Malnutrition*, Humans ; Child ; Child, Preschool ; Infant ; Male ; Female

Implementing collaborative documentation in outpatient behavioral health.

Authors: Matthews EB Peral M

Source: Psychiatric rehabilitation journal [Psychiatr Rehabil J] 2025 Dec; Vol. 48 (4), pp. 274-282. Date of Electronic Publication: 2025 Jul 10.

Publication Type: Journal Article

Journal Info: Publisher: American Psychological Association Country of Publication: United States NLM ID: 9601800 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1559-3126 (Electronic) Linking ISSN: 1095158X NLM ISO Abbreviation: Psychiatr Rehabil J Subsets: MEDLINE

MeSH Terms: Patient-Centered Care*/organization & administration , Documentation*/methods , Documentation*/standards , Ambulatory Care* , Psychiatric Rehabilitation*/methods , Mental Health Services*/organization & administration, Humans ; Qualitative Research ; Focus Groups ; Adult ; Male

AI-based assessment of pulmonology inpatient consultation note completeness: predicting documentation gaps and response delays.

Authors: Yazici DA Satici C Bahadir A et al.

Source: International journal of medical informatics [Int J Med Inform] 2025 Dec; Vol. 204, pp. 106072. Date of Electronic Publication: 2025 Aug 05.

Publication Type: Journal Article

Journal Info: Publisher: Elsevier Science Ireland Ltd Country of Publication: Ireland NLM ID: 9711057 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1872-8243 (Electronic) Linking ISSN: 13865056 NLM ISO Abbreviation: Int J Med Inform Subsets: MEDLINE

MeSH Terms: Documentation*/standards , Referral and Consultation* , Artificial Intelligence* , Pulmonary Medicine* , Electronic Health Records* , Inpatients*, Humans ; Natural Language Processing ; Retrospective Studies ; Machine Learning

Trends of Problems with Functioning in Everyday Life for Children Post Brain Tumor Treatment: As Documented in Professional Records.

Authors: Björklund AC Coci AI Granlund M et al.

Source: Comprehensive child and adolescent nursing [Compr Child Adolesc Nurs] 2025 Dec; Vol. 48 (4), pp. 207-228. Date of Electronic Publication: 2025 Jul 09.

Publication Type: Journal Article

Journal Info: Publisher: Taylor & Francis Group Country of Publication: England NLM ID: 101682864 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 2469-4207 (Electronic) NLM ISO Abbreviation: Compr Child Adolesc Nurs Subsets: MEDLINE

MeSH Terms: Brain Neoplasms*/complications , Brain Neoplasms*/psychology , Brain Neoplasms*/therapy , Activities of Daily Living*/psychology , Documentation*/methods , Documentation*/standards, Humans ; Female ; Child ; Male ; Adolescent

Artificial intelligence in the non-clinical laboratory: enhancing good laboratory and documentation practices.

Authors: Zai K Mukti AP Notty GS et al.

Source: International journal of pharmaceutics [Int J Pharm] 2025 Nov 30; Vol. 685, pp. 126266. Date of Electronic Publication: 2025 Oct 10.

Publication Type: Journal Article; Review

Journal Info: Publisher: Elsevier/North-Holland Biomedical Press Country of Publication: Netherlands NLM ID: 7804127 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1873-3476 (Electronic) Linking ISSN: 03785173 NLM ISO Abbreviation: Int J Pharm Subsets: MEDLINE

MeSH Terms: Artificial Intelligence*/standards , Laboratories*/standards , Laboratories*/legislation & jurisprudence , Documentation*/standards, Humans ; Quality Control

Structured panendoscopy reports improve report completeness and documentation time.

Authors: Bärhold F Wolpert SM Ernst BP et al.

Source: Scientific reports [Sci Rep] 2025 Nov 25; Vol. 15 (1), pp. 42021. Date of Electronic Publication: 2025 Nov 25.

Publication Type: Journal Article

Journal Info: Publisher: Nature Publishing Group Country of Publication: England NLM ID: 101563288 Publication Model: Electronic Cited Medium: Internet ISSN: 2045-2322 (Electronic) Linking ISSN: 20452322 NLM ISO Abbreviation: Sci Rep Subsets: MEDLINE

MeSH Terms: Documentation*/methods , Documentation*/standards , Endoscopy*/methods, Humans ; Surveys and Questionnaires ; Female ; Male ; Middle Aged ; Time Factors

The Impact of Clinical Documentation Integrity Programs on Diagnosis Documentation.

Authors: Sanderson AL Lo L Arafiles W et al.

Source: Advances in health information science and practice [Adv Health Inf Sci Pract] 2025 Nov 19; Vol. 1 (2), pp. CGJA8827. Date of Electronic Publication: 2025 Nov 19 (Print Publication: 2025).

Publication Type: Journal Article

Journal Info: Publisher: American Health Information Management Association Country of Publication: United States NLM ID: 9919050935306676 Publication Model: eCollection Cited Medium: Internet ISSN: 3066-5825 (Electronic) Linking ISSN: 30665825 NLM ISO Abbreviation: Adv Health Inf Sci Pract Subsets: MEDLINE

MeSH Terms: Documentation*/standards , Electronic Health Records*/standards, Humans ; Hospitals, Pediatric/statistics & numerical data ; Diagnosis-Related Groups ; Child

Reducing Epinephrine Use and Enhancing Documentation for Chemotherapy Hypersensitivity Reactions.

Authors: Neal S Buck J Sharpe E et al.

Source: Clinical journal of oncology nursing [Clin J Oncol Nurs] 2025 Nov 19; Vol. 29 (6), pp. 497-501.

Publication Type: Journal Article

Journal Info: Publisher: Oncology Nursing Press Country of Publication: United States NLM ID: 9705336 Publication Model: Print Cited Medium: Internet ISSN: 1538-067X (Electronic) Linking ISSN: 10921095 NLM ISO Abbreviation: Clin J Oncol Nurs Subsets: MEDLINE

MeSH Terms: Epinephrine*/therapeutic use , Epinephrine*/administration & dosage , Drug Hypersensitivity*/drug therapy , Documentation*/standards , Antineoplastic Agents*/adverse effects , Anaphylaxis*/drug therapy , Anaphylaxis*/chemically induced, Humans ; Female ; Male ; Middle Aged ; Aged ; Quality Improvement ; Adult

Prompting Serious Illness Conversation in Community Oncology Through Education, Shared Documentation, and Nudges.

Authors: Serino G; Gillian Serino.

Source: Clinical journal of oncology nursing [Clin J Oncol Nurs] 2025 Nov 19; Vol. 29 (6), pp. 491-496.

Publication Type: Journal Article

Journal Info: Publisher: Oncology Nursing Press Country of Publication: United States NLM ID: 9705336 Publication Model: Print Cited Medium: Internet ISSN: 1538-067X (Electronic) Linking ISSN: 10921095 NLM ISO Abbreviation: Clin J Oncol Nurs Subsets: MEDLINE

MeSH Terms: Advance Care Planning* , Neoplasms*/nursing , Documentation* , Palliative Care* , Communication* , Medical Oncology*/education, Humans ; Male ; Female ; Middle Aged ; Aged ; Adult

Exploring documentation and reporting practices in malaria tracking: a mixed-methods study among formal drug retail shops in Hohoe Municipal, Ghana.

Authors: Loglo V Gmayinaam VU Ampomah MA et al.

Source: Malaria journal [Malar J] 2025 Nov 14; Vol. 24 (1), pp. 399. Date of Electronic Publication: 2025 Nov 14.

Publication Type: Journal Article

Journal Info: Publisher: BioMed Central Country of Publication: England NLM ID: 101139802 Publication Model: Electronic Cited Medium: Internet ISSN: 1475-2875 (Electronic) Linking ISSN: 14752875 NLM ISO Abbreviation: Malar J Subsets: MEDLINE

MeSH Terms: Malaria*/epidemiology , Documentation*/statistics & numerical data , Pharmacies*/statistics & numerical data, Ghana/epidemiology ; Cross-Sectional Studies ; Adult ; Humans ; Young Adult ; Female ; Male ; Disease Notification/statistics & numerical data