Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System.
Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system.
Author(s): Evans, Christopher S, Bunn, Barry, Reeder, Timothy, Patterson, Leigh, Gertsch, Dustin, Medford, Richard J
DOI: 10.1055/a-2301-7496