medical chart documentation
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Notes
- in 2019, physicians in the U.S. spent ~125,000,000 hours outside office hours completing medical documentation[1]
More general terms
More specific terms
- alarm systems assessed, GERD
- anemia plan of care documented, ESRD
- antibiotic neither prescribed nor dispensed, URI/PHAR/A-BRONCH
- antihistamines/decongestants neither prescribed nor recommended, OME
- AREDS formulation prescribed or recommended
- assessment of coronary artery disease
- assessment of pneumococcus immunization status
- auricular or periauricular pain assessed, AOE
- barium swallow not ordered
- clinical genetics documentation
- colonoscopy report
- dashboard; relative value units (RVUs)
- discharge summary
- documentation for back pain
- documentation for epilepsy
- documentation for major depressive disorder
- documentation for melanoma
- documentation for palliative care
- documentation of advance directives
- documentation of atrial fibrillation, STR
- documentation of bone scan for prostate cancer
- documentation of falls in the elderly
- documentation of fracture in osteoporosis
- documentation of hearing test within 6 months prior to tympanostomy
- documentation of iron stores prior to initiating erythropoietin therapy
- documentation of labs for chronic renal failure
- documentation of mental health assessment prior to intervention, BkP
- documentation of PSA/staging/Gleason score for prostate cancer
- documentation of treatment for nephropathy
- dyspnea not screened, Pall Cr
- GI & renal risk factors assessed for OA patients prescribed NSAIDs
- glaucoma plan of care documented
- glucorticoid management plan documented, RA
- heart failure assessed, CAD/HF
- hemoglobin oxygen saturation < 88%
- hydration status assessed, CAP
- hydration status documented, dehydrated
- hydration status documented, normally hydrated
- hypertension plan of care documentation
- imaging documentation, BkP
- immunity to hepatitis A
- immunity to hepatitis B
- interval of >= 3 years since last colonoscopy
- ischemic stroke symptom onset < 3 hours prior to arrival
- ischemic stroke symptom onset >= 3 hours prior to arrival
- low risk for retinopathy, DM
- medical chart documentation for dementia
- medical chart documentation, atrial fibrillation/atrial flutter
- medical chart documentation, GERD
- medical chart documentation, hepatitis C
- medical chart documentation, RhD negative
- medical chart documentation, RhD positive
- medical chart documentation, rheumatoid arthritis
- pain severity assessed, ONC
- patient not receiving erythropoiesis-stimulating agent, CKD
- patient not receiving erythropoietin therapy, HEM
- preoperative documentation for cataracts surgery
- prostate cancer risk of recurrence
- suicide risk assessed, MDD
- systemic antimicrobial therapy not prescribed, AOE
- systemic corticosteroids not prescribed, OME
- thromboembolic risk factors assessed for atrial fibrillation
- urinary incontinence characterized
- urinary incontinence plan of care documented
Additional terms
References
- ↑ 1.0 1.1 Gaffney A et al. Medical documentation burden among US office-based physicians in 2019: A national study. JAMA Intern Med. 2022 Mar 28:e220372 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35344006 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2790396