Electronic medical documentation

Documentation of Dual Sensory Impairment in Electronic Medical Records.

PURPOSE OF THE STUDY To examine the documentation of sensory impairment in the electronic medical records (EMRs) of Veterans with both hearing and vision losses (dual sensory impairment [DSI]). DESIGN AND METHODS A retrospective chart review of the EMRs of 20 patients with DSI was conducted. Providers' documentation of the presence of sensory impairment, the use of assistive technology during...

Clinical Documentation in Emergency Departments : Integrating paper - based documentation into the electronic medical record

Electronic Information Security Documentation

Effective security management depends upon good risk management, which is itself based upon a reliable risk assessment, involving data collection of all the facets influencing system risk. Such data collection is often an extremely onerous task, particularly if a substantial proportion of the required information is not adequately documented. Hence comprehensive, updated information security do...

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

INTRODUCTION Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determ...

documentation of electronic evidence in punitive issues

0