Proactive documentation using AI reviews all patient data to reduce clinician burden and enhance care quality and efficiency.

Nursing documentation is a cornerstone of contemporary healthcare, integrating systematic recording of patient observations, interventions, and outcomes with the aim of enhancing effective care ...

Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at ...

Nursing documentation is often cited as a factor for nursing burnout, and many organizations are rethinking the approach to the old philosophy of "If it's not documented, it didn't happen." Banner ...

Rachel Moscicki is on the leading edge of a movement for nurses to use speech recognition and natural-language-processing technology to record their clinical documentation, saving time and optimizing ...

Before EHRs were implemented, they were touted as a huge step forward in patient care. They were supposed to be more accurate, safer, timelier, and faster. Computers were going to free up nurses to ...

VOL: 103, ISSUE: 6, PAGE NO: 32-33 Kim O?Connor, BSc, RGN, is head of practice development; Therese Earl, RGN, is a professional development nurse; Petra Hancock, BSc, RGN, is a practice facilitator ...

ICD-10 is the 10th edition of the International Classification of Diseases published by the World Health Organization. We have used ICD-9 since the 1970s and those codes have limitations that prevent ...

In one of the few recent studies to examine this question objectively, Yee and colleagues [8] assessed time spent by nurses documenting on EHRs compared with paper charting. A cross-sectional analysis ...