Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation

Search Page

Filters

My NCBI Filters

Results by year

Table representation of search results timeline featuring number of search results per year.

Year Number of Results
2018 1
2019 6
2020 5
2021 7
2022 4
2023 5
2024 3

Text availability

Article attribute

Article type

Publication date

Search Results

26 results

Results by year

Filters applied: . Clear all
Page 1
Charting Practices to Protect Against Malpractice: Case Reviews and Learning Points.
Ghaith S, Moore GP, Colbenson KM, Lindor RA. Ghaith S, et al. West J Emerg Med. 2022 Apr 28;23(3):412-417. doi: 10.5811/westjem.2022.1.53894. West J Emerg Med. 2022. PMID: 35679491 Free PMC article. Review.
Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians' documentation and minimize their liability risks. METHODS: We used Thomson Reuters Westlaw legal database to identify malpractice cases re …
Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians' documenta …
Medico-legal issues related to emergency physicians' documentation in Canadian emergency departments.
Smith JD, Lemay K, Lee S, Nuth J, Ji J, Montague K, Garber GE. Smith JD, et al. CJEM. 2023 Sep;25(9):768-775. doi: 10.1007/s43678-023-00576-1. Epub 2023 Aug 30. CJEM. 2023. PMID: 37646956 Free PMC article.
This study provides examples of documentation issues attributed to physicians practicing emergency medicine as identified by peer experts in civil legal actions, regulatory authority complaints (College) and hospital complaints (collectively, medico-legal cas …
This study provides examples of documentation issues attributed to physicians practicing emergency medicine as identified by peer exp …
Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates.
Kauzner S, Heckel M, Ostgathe C, Schneider M, Bausewein C, Schildmann E, Kremling A, Ziegler K, Klein C. Kauzner S, et al. J Palliat Med. 2023 Sep;26(9):1277-1284. doi: 10.1089/jpm.2022.0476. Epub 2023 May 4. J Palliat Med. 2023. PMID: 37155703 Review.
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by …
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliativ …
Documentation during neonatal resuscitation: a systematic review.
Avila-Alvarez A, Davis PG, Kamlin COF, Thio M. Avila-Alvarez A, et al. Arch Dis Child Fetal Neonatal Ed. 2021 Jul;106(4):376-380. doi: 10.1136/archdischild-2020-319948. Epub 2020 Nov 26. Arch Dis Child Fetal Neonatal Ed. 2021. PMID: 33243927
OBJECTIVE: Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. ...CONCLUSIONS: There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of …
OBJECTIVE: Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. .. …
Development and Validation of Claims-Based Definitions to Identify Incident and Prevalent Inflammatory Bowel Disease in Administrative Healthcare Databases.
Dawwas GK, Weiss A, Constant BD, Parlett LE, Haynes K, Yang JY, Brensinger C, Wu Q, Pate V, Jonsson Funk M, Schaubel DE, Hurtado-Lorenzo A, David Kappelman M, Lewis JD. Dawwas GK, et al. Inflamm Bowel Dis. 2023 Dec 5;29(12):1993-1996. doi: 10.1093/ibd/izad053. Inflamm Bowel Dis. 2023. PMID: 37043675 Free PMC article. Review.
The claims-based incident diagnosis date needed to be within 90 days of that recorded in the medical record to be valid. RESULTS: We reviewed 111 charts of patients with a potentially incident diagnosis. The positive predictive value (PPV) of the claims algorithm was 91% ( …
The claims-based incident diagnosis date needed to be within 90 days of that recorded in the medical record to be valid. RESULTS: We reviewe …
Supracondylar Humeral Fracture Documentation: A Performance Improvement Study.
Sullivan JA, Gregory JR, Wiley KF, Parris D, Stoner J. Sullivan JA, et al. J Pediatr Orthop. 2019 Nov/Dec;39(10):e777-e781. doi: 10.1097/BPO.0000000000001372. J Pediatr Orthop. 2019. PMID: 31095013
A retrospective chart review was used to collect documentation information before the implementation of the clinical pathway and a prospective study design was used to collect information after the implementation of the clinical pathway. ...Although we did see impro …
A retrospective chart review was used to collect documentation information before the implementation of the clinical pathway a …
A retrospective chart review of trauma-related documentation in an Australian substance use treatment service.
Harvey LR, Hopkins R, Truscott M, Marel C, Slade T, Mills KL. Harvey LR, et al. Drug Alcohol Rev. 2023 Feb;42(2):373-383. doi: 10.1111/dar.13575. Epub 2022 Nov 14. Drug Alcohol Rev. 2023. PMID: 36377196 Free PMC article.
This study examined one aspect of clinical care-clinical documentation-and sought to systematically assess the documentation of trauma-related comorbidities and their treatment in a substance use treatment setting. ...Rates of documentation of trauma-related …
This study examined one aspect of clinical care-clinical documentation-and sought to systematically assess the documentation o …
Considerations for Creating a Restricted Data Environment with Complete Primary Care Electronic Medical Record Data.
Lees J, Theal R, Barber D, Herman C. Lees J, et al. Ann Fam Med. 2023 Jan 1;21(21 Suppl 1):4084. doi: 10.1370/afm.21.s1.4084. Ann Fam Med. 2023. PMID: 36972526 Free PMC article.
DFM members consulted with Queen's University computing, privacy, legal, and ethics experts to develop data access processes, policies and governance, agreements, and associated documents. Initial QFAMR projects involved applying and improving de-identification processes f …
DFM members consulted with Queen's University computing, privacy, legal, and ethics experts to develop data access processes, policie …
Advance directives in Austrian intensive care units: An analysis of prevalence and barriers.
Köstenberger M, Diegelmann S, Terlutter R, Bidmon S, Neuwersch S, Likar R. Köstenberger M, et al. Resusc Plus. 2020 Jun 28;3:100014. doi: 10.1016/j.resplu.2020.100014. eCollection 2020 Sep. Resusc Plus. 2020. PMID: 34223298 Free PMC article.
PURPOSE: To investigate the prevalence of advance directives, healthcare proxies, and legal representatives in Austrian intensive care units (ICUs), and to explore barriers faced by adults engaged in the contemplation and documentation phase of the advance care plan …
PURPOSE: To investigate the prevalence of advance directives, healthcare proxies, and legal representatives in Austrian intensive car …
Does an Orthopedic Ward Round Pro Forma Improve Inpatient Documentation?
Vukanic D, Kelly EG, Cleary SM. Vukanic D, et al. J Patient Saf. 2021 Dec 1;17(8):553-556. doi: 10.1097/PTS.0000000000000678. J Patient Saf. 2021. PMID: 32168277
INTRODUCTION: Thorough documentation is of utmost importance in a patient hospital experience. ...With most patient records entered by junior level of staff, it is important to ensure that adequate documentation occurs. METHODS: We analyzed notes entered in patient …
INTRODUCTION: Thorough documentation is of utmost importance in a patient hospital experience. ...With most patient records entered b …
26 results