Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record.
Communication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool.
Author(s): Fanucchi, Laura, Yan, Donglin, Conigliaro, Rosemarie L
DOI: 10.4338/ACI-2016-02-CR-0025