Medical record keeping

Innovations

Rheumatology Clinics Leverage Technology and Redesign Care Processes to Provide Physicians Relevant Patient Information, Improving Symptoms and Adherence to Recommended Care 07/06/11

Rheumatology clinics used information technology and redesigned associated care process to allow clinicians to access relevant patient information and focus scarce visit time on solving problems, leading to improvements in the provision of needed services and patient-reported symptoms.

Multispecialty Practice Uses Electronic Templates to Provide Customized Support at Every Visit, Contributing to Improved Patient Behaviors and Outcomes 06/03/11

Using electronic templates, nurses and physicians provide a personalized report to patients at virtually every visit, with the goal of improving health-related behaviors; the program has contributed to a leveling off in the prevalence of overweight/obesity, above-average quit rates among smokers, better blood glucose control, and fewer racial disparities in chronic care.

Skin Assessments Conducted as Part of Patient Intake Improve Documentation of Pressure Ulcers on Admission, Reduce Incidence During Stay 05/30/11

Nurses perform a baseline skin assessment on every newly admitted patient, leading to improvements in the identification and documentation of pressure ulcers on admission and to lower incidence of pressure ulcers.

Registry Assists Physicians and School Nurses in Managing Childhood Asthma, Leading to Fewer Inpatient Admissions and Emergency Department Visits 05/24/11

A Web-based registry assists primary care physicians, pediatricians, and school nurses in managing childhood asthma, leading to significant reductions in inpatient admissions and emergency department visits.

Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors 05/04/11

A computerized decision support system uses algorithms and real-time patient information to guide the resuscitation of trauma patients, leading to fewer medical errors.

Postdischarge Followup Calls to Skilled Nursing Facilities Reduce Heart Failure Readmissions by Two-Thirds 04/10/11

Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, leading to a significant reduction in readmissions and associated cost savings.

Electronic Alerts, Patient Education, and Performance Reports Improve Adherence to Guideline Designed to Reduce Early Elective Inductions 03/29/11

Electronic alerts, patient education, and provider performance reports promote adherence to a guideline covering early elective inductions, leading to a significant decline in such inductions, shorter average labor, and fewer newborn complications.

Electronic System for Tracking Test Results Pending at Hospital Discharge Draws Little Use or Enthusiasm From Hospitalists 03/11/11

Hospitalists used an electronic application to track the pending test results of recently discharged inpatients; the application proved to be of limited value, with nearly half of hospitalists never using it and nearly all reporting multiple barriers to doing so.

Electronic Standing Orders Highlight Care Gaps and Allow Nonphysicians to Address Them, Leading to Increased Provision of Preventive Services 03/08/11

Primary care practices incorporate standing orders for preventive care services into the electronic health record, allowing nonphysician clinical staff to fill gaps in care; the program substantially increased the provision of needed services to eligible patients.

Unobtrusive, Actionable Reminders and Performance Feedback Improve Physician Performance on Standardized Quality Measures 02/17/11

Through its commercial electronic medical record system, a large internal medicine practice provides physicians with unobtrusive reminders related to 16 standardized measures and makes it easy for them to order recommended tests or treatment or document legitimate exceptions, leading to better performance on these measures.

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