Medical record keeping

Innovations

Computerized Alerts Do Not Influence Physician Ordering Habits or Improve Clinical Outcomes for Elderly, Hospitalized Patients With Cognitive Impairment 09/14/12

Computerized alerts did not influence physician ordering habits or improve clinical outcomes for elderly, hospitalized patients with cognitive impairment.

Multihospital System Uses Proactive Screening, Algorithms, and Tools To Improve Sepsis Care, Leading to More Appropriate Care and Better Outcomes 05/29/12

A regional health system with 21 hospitals implemented a comprehensive sepsis care initiative featuring proactive screening in the emergency department, algorithms to guide evidence-based treatment, and tools to support the provision of appropriate care, leading to better diagnosis, more appropriate care, lower mortality rates, and more patients meeting clinical targets.

Statewide Program Supports Medical Homes Through Multidisciplinary Teams, Easy Access to Information, and Incentives, Leading to Lower Costs and Better Care 05/18/12

A statewide program supports physician practices through multidisciplinary community-based health teams, preventive health expertise, easy access to needed information via electronic systems, and financial incentives, leading to lower utilization and growth in health care spending and enhanced provision of appropriate services.

Health System Offers Routine Tests Without Need for Physician Order, Enhancing Access for Small but Growing Number of Satisfied Patients 05/04/12

A health system allows patients to receive certain routine laboratory tests without a physician's order, enhancing access to these tests and generating positive feedback.

Care Management Protocols and User-Friendly Forms Embedded in Electronic Medical Record Improve Documentation, Coding Accuracy, and Readability of Visit Notes 03/15/12

Protocol-based care management tools and simplified documentation forms embedded in the electronic medical record improve documentation, the readability of notes, and coding accuracy in military health care facilities.

Online Patient Access to Visit Notes Generates Positive Early Reviews From Patients and Primary Care Physicians 03/01/12

Primary care doctors offer patients online access to office visit notes, generating high levels of satisfaction and multiple benefits for both patients and physicians.

Standardized Order Bundles and Ongoing Care Coordination Expedite Testing and Specialty Consults for Primary Care Patients With Common Conditions 01/14/12

Primary care physicians order standardized bundles of tests and specialty referrals for common diagnoses, which are then managed by a care coordination team, resulting in expedited patient care and high physician satisfaction.

Community Pediatricians Use Software to Diagnose and Manage Attention-Deficit/Hyperactivity Disorder, Leading to Improvements in Symptoms 11/26/11

Pediatricians in community practice use computer software and a manual to diagnose and manage attention-deficit/hyperactivity disorder, leading to significant improvements in symptoms.

Daily Nurse Review of Key Health Indicators Reduces Inpatient and Emergency Department Use for Patients on Dialysis 08/04/11

Nurses remotely monitor key indicators of end-stage renal disease patients and intervene as appropriate, leading to less inpatient and emergency department use and higher quality of life.

Mental Health Patients Track Moods Through Web Application, Generating Greater Adherence to Daily Tracking, Better Treatment Decisions, and High Satisfaction 07/25/11

Individuals with depression and/or other mood disorders log and track their daily mood through a mobile phone application, leading to higher adherence than with paper-based tools, better treatment decisions, and positive feedback from patients and clinicians.

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