Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation mydrg.de

Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation (Critical Care Medicine).

The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists.

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Conclusions:
Documentation of specific diagnoses in the medical record is important in the
broad context of our existing medical system but there is an associated burden
in doing so. Widespread implementation of electronic medical record systems has
inadvertently led to clinician dissatisfaction and burnout. [...]

Quelle: Critical Care Medicine, 23.03.2020