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Improving clinical documentation in an EMR world. 2010

Thomas Payne
IT services, UW Medicine, Seattle, USA. tpayne@u.washington.edu

Hospitals can take three steps to ensure successful integration of clinical documentation with an electronic medical record: Engage physicians and make sure they understand the process. Make the process simple for physicians to use. Train registered nurse documentation specialists to request documentation clarifications.

UI MeSH Term Description Entries
D010820 Physicians Individuals licensed to practice medicine. Physician
D003299 Cooperative Behavior The interaction of two or more persons or organizations directed toward a common goal which is mutually beneficial. An act or instance of working or acting together for a common purpose or benefit, i.e., joint action. (From Random House Dictionary Unabridged, 2d ed) Compliant Behavior,Behavior, Compliant,Behavior, Cooperative,Compliant Behaviors,Cooperative Behaviors
D004493 Education Acquisition of knowledge as a result of instruction in a formal course of study. Literacy Programs,Training Programs,Activities, Educational,Educational Activities,Workshops,Activity, Educational,Educational Activity,Literacy Program,Program, Literacy,Program, Training,Programs, Literacy,Programs, Training,Training Program,Workshop
D005568 Forms and Records Control A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records. Records Control,Forms Control,Records Management,Controls, Records,Management, Records,Records Controls
D006751 Hospital Information Systems Integrated, computer-assisted systems designed to store, manipulate, and retrieve information concerned with the administrative and clinical aspects of providing medical services within the hospital. Multi-Hospital Information Systems,Information System, Hospital,Information System, Multihospital,Information Systems, Hospital,Information Systems, Multihospital,Multihospital Information Systems,Hospital Information System,Information System, Multi-Hospital,Information Systems, Multi-Hospital,Multi Hospital Information Systems,Multi-Hospital Information System,Multihospital Information System
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D016347 Medical Records Systems, Computerized Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record. Automated Medical Records Systems,Computerized Medical Records Systems,Automated Medical Record System,Automated Medical Record Systems,Automated Medical Records System,Computerized Medical Record System,Computerized Medical Record Systems,Computerized Medical Records System,Computerized Patient Medical Records,Medical Record System, Automated,Medical Record System, Computerized,Medical Record Systems, Automated,Medical Record Systems, Computerized,Medical Records System, Automated,Medical Records System, Computerized,Medical Records Systems, Automated

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