Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department.

ABSTRACT:

Objectives

Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED.

Methods

This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automaticall

SUBMITTER: Turer RW 

PROVIDER: S-EPMC9668511 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature