Objective To evaluate the completeness of diagnosis recording in problem lists in a hospital
electronic health record (EHR) system during the COVID-19 pandemic. Design …

Background Correctly structured problem lists in electronic health records (EHRs) offer
major benefits to patient care. Without structured lists, diagnosis information is often …

Objective To determine the content priorities and design preferences for a longitudinal care
plan (LCP) among caregivers and healthcare providers who care for children with medical …

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement
endeavor as it is ultimately the medical record that is measured in assessing change …

Background Problem lists represent an integral component of high-quality care. However,
they are often inaccurate and incomplete. We studied the effects of alerts integrated into the …

Background Accurate recording of problems and diagnoses in health records is key to safe
and effective patient care, yet it is often done poorly. Electronic health record systems vary in …

Purpose The purpose of this study was to evaluate the current state of problem list
maintenance at an academic medical center. Summary We included problem list data for …

Patients with heart failure (HF) often suffer from multimorbidity. Rapid assessment of
multimorbidity is important for minimizing the risk of harmful drug-disease and drug-drug …

Background Problem-oriented documentation is an accepted method of note construction
which facilitates clinical thought processes. However, problem-oriented documentation is …

Objective To determine the impact of documentation workflow on the accuracy of coded
diagnoses in electronic health records (EHRs). Design Cross-sectional study. Participants …