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http://dx.doi.org/10.1002/jhm.13113 | DOI Listing |
Effective documentation and coding in health care are crucial for patient care, safety, workflow improvement and accurate billing. This quality improvement study aimed to enhance History and Physical (H&P) note documentation and charge capture processes to integrate coding and billing aspects, capture authentic work, preserve the H&P's integrity and align H&P-related revenue with actual performance. A multidisciplinary team, including divisional leadership and specialists in documentation improvement, electronic health records, lean/six sigma methodology, a nocturnist and a senior-level physician coding auditor, initiated a quality improvement project.
View Article and Find Full Text PDFJ Gen Intern Med
January 2025
Northwell Health, New Hyde Park, NY, USA.
Background: Oropharyngeal dysphagia (dysphagia) is a common (up to 86%) and devastating syndrome in hospitalized older adults with dementia.
Objective: To describe the perspectives of dysphagia management in hospitalized patients with dementia among hospital medicine providers (i.e.
BMJ Open
January 2025
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Objective: To identify physician perspectives on factors associated with physician burnout, protective factors against burnout, and to seek potential solutions for this pervasive problem.
Design: A qualitative study with semistructured focus group interviews using a systematic framework analysis.
Setting And Participants: Physicians from general internal medicine (GIM) and the emergency department (ED) at two urban tertiary care hospitals in Vancouver, Canada, were recruited.
JAMA Netw Open
January 2025
Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield.
Importance: Despite guideline recommendations to use low-molecular-weight heparins (LMWHs) or direct oral anticoagulants in the treatment of most patients with acute pulmonary embolism (PE), US-based studies have found increasing use of unfractionated heparin (UFH) in hospitalized patients.
Objective: To identify barriers and facilitators of guideline-concordant anticoagulation in patients hospitalized with acute PE.
Design, Setting, And Participants: This qualitative study conducted semistructured interviews from February 1 to June 3, 2024, that were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis.
J Hosp Med
December 2024
Division of Hospital Medicine, University of Kentucky, Lexington, Kentucky, USA.
Background: Clinician electronic actions within the electronic health record (EHR) are captured seamlessly in real-time during regular work activities in all major EHRs. Analysis of this EHR use metadata, such as audit log data, is increasingly used to understand the impact of work design on critical patient, workforce, and organizational outcomes.
Objective: Understand experiences and perspectives influencing the use and implementation of audit log data into practice.
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