CIO Stories, III Methodist Healthcare System, San Antonio: Redesign of Clinical Documentation
Documentation time had increased.
Complex care plans did not effectively communicate patient problems.
Excessive interventions were needed to support daily documentation.
The patient care plan did not connect with the daily documentation record.
Accuracy of the medical record decreased.
Fragmented data were produced.
Medical records accumulated duplicate and conflicting information.
Extracting concurrent and retrospective data proved difficult.
Physician dissatisfaction with nursing and the medical record had increased.
KeywordsAdvance Directive Nutritional Risk Clinical Documentation Respiratory Therapy Documentation Time
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