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Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation
Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation
BackgroundNumbers of clinical documentation integrity specialists (CDIS) and CDI programs have increased rapidly. CDIS rev...
Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia
Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia
Background: A large proportion of patients presenting to hospitals have experienced a previous adverse drug reaction (ADR)...
Identification of root causes of clinical coding problems in Iranian hospitals
Identification of root causes of clinical coding problems in Iranian hospitals
BackgroundImproving the quality of coded data requires the identification and evaluation of the root causes of clinical co...
Is training doctors in medical certification effective? Evidence from a prospective study in the Philippines
Is training doctors in medical certification effective? Evidence from a prospective study in the Philippines
BackgroundCorrect certification of causes of death by physicians according to International Classification of Diseases (IC...
Read science news critically and look for original studies: An example of misleading headlines related to COVID-19 vaccines in mainstream media
Read science news critically and look for original studies: An example of misleading headlines related to COVID-19 vaccines in mainstream media
Access to society journal content varies across our titles. If you have access to a journal via a society or association ...
Family violence homicide rates: a state-wide comparison of three data sources in Victoria, Australia
Family violence homicide rates: a state-wide comparison of three data sources in Victoria, Australia
BackgroundFamily violence homicide (FVH) is a major public health and social problem in Australia. FVH trend rates are key...
Impact of implementing structured note templates on data capture for hernia surgery
Impact of implementing structured note templates on data capture for hernia surgery
Background:Electronic medical record notes have been determined to be lacking in quality, accessibility and content. Struc...
Factors affecting clinicians’ adherence to principles of diagnosis documentation: A concept mapping approach for improved decision-making
Factors affecting clinicians’ adherence to principles of diagnosis documentation: A concept mapping approach for improved decision-making
Background:The quality of data in electronic health records (EHRs) depends on adherence of clinicians to principles of dia...
A qualitative investigation into clinical documentation: why do clinicians document the way they do?
A qualitative investigation into clinical documentation: why do clinicians document the way they do?
Background:Clinical documentation is a fundamental component of patient care. The transition from paper based to electroni...
An investigation of the status and maturity of hospitals’ health information governance in Victoria, Australia
An investigation of the status and maturity of hospitals’ health information governance in Victoria, Australia
Background:Health information governance (IG) in Australian hospitals was hitherto unexplored.Objectives:To determine hosp...
The attributes of hospital-based coronary artery diseases registries with a focus on key registry processes: A systematic review
The attributes of hospital-based coronary artery diseases registries with a focus on key registry processes: A systematic review
Background:The management of data on coronary artery disease (CAD) plays a significant role in controlling the disease and...
Utility of SNOMED CT in automated expansion of clinical terms in discharge summaries: Testing issues of coverage
Utility of SNOMED CT in automated expansion of clinical terms in discharge summaries: Testing issues of coverage
Objective:This study tests coverage of SNOMED CT as an expansion source in the process of automated expansion of clinical ...
A learning agenda to build the evidence base for strengthening global health information systems
A learning agenda to build the evidence base for strengthening global health information systems
Background:Evidence-based interventions are necessary for planning and investing in health information systems (HIS) and f...
Can electronic assessment tools improve the process of shared decision-making? A systematic review
Can electronic assessment tools improve the process of shared decision-making? A systematic review
Background:Patient involvement in decision-making plays a prominent role in improving the quality of healthcare. Despite t...
Factors affecting the acceptance of integrated electronic personal health records in Saudi Arabia: The impact of e-health literacy
Factors affecting the acceptance of integrated electronic personal health records in Saudi Arabia: The impact of e-health literacy
Background:National implementation of electronic personal health record (ePHR) systems is of vital importance to governmen...
Verification of administrative data to measure palliative care at terminal hospital stays
Verification of administrative data to measure palliative care at terminal hospital stays
Background:Administrative data and clinician documentation have not been directly compared for reporting palliative care, ...
Attitudes and perceptions of traditional health practitioners towards documentation of patient health information in their practice in eThekwini Municipality, KwaZulu-Natal, Natal Province, South Africa
Attitudes and perceptions of traditional health practitioners towards documentation of patient health information in their practice in eThekwini Municipality, KwaZulu-Natal, Natal Province, South Africa
Background:Documentation of patient health information in the form of patient medical records (PMRs) is an essential, ethi...
Social media in health communication: A literature review of information quality
Social media in health communication: A literature review of information quality
Background:Social media is used in health communication by individuals, health professionals, disease centres and other he...
Discharge status of the patient: evaluating hospital data quality with a focus on long-term and palliative care patient data
Discharge status of the patient: evaluating hospital data quality with a focus on long-term and palliative care patient data
ACSS (2017) Monitoring the Portuguese National Network for Long-term Integrated Care – 2016 (Monitorização da Rede Nacio...
Recognising complexity: Foregrounding vulnerable and diverse populations for inclusive health information management research
Recognising complexity: Foregrounding vulnerable and diverse populations for inclusive health information management research
Cappetta, A, Lago, L, Potter, J (2020) Under-coding of dementia and other conditions indicates scope for improved patien...
Awareness of, attitudes towards, and practices of health information management professionals in South Korea relating to privacy of personal health information
Awareness of, attitudes towards, and practices of health information management professionals in South Korea relating to privacy of personal health information
Background: While information and communication technology has continued to advance, privacy of personal health informatio...
Training and experience of coding with the World Health Organization’s International Classification of Diseases, Eleventh Revision
Training and experience of coding with the World Health Organization’s International Classification of Diseases, Eleventh Revision
Background:The new International Classification of Diseases, Eleventh Revision for Mortality and Morbidity Statistics (ICD...
Improved efficiency of patient admission with electronic health records in neurosurgery
Improved efficiency of patient admission with electronic health records in neurosurgery
Background:Electronic health records (EHRs) may be controversial but they have the potential to improve patient care. We i...
Analysing EHR navigation patterns and digital workflows among physicians during ICU pre-rounds
Analysing EHR navigation patterns and digital workflows among physicians during ICU pre-rounds
Background:Some physicians in intensive care units (ICUs) report that electronic health records (EHRs) can be cumbersome a...
Awareness, attitude and practice towards personal health information privacy among health information management professionals in South Korea
Awareness, attitude and practice towards personal health information privacy among health information management professionals in South Korea
Background: While information and communication technology has continued to advance, privacy of personal health informatio...
Comparison of routine blood alcohol tests and ICD-10-AM coding of alcohol involvement for major trauma patients
Comparison of routine blood alcohol tests and ICD-10-AM coding of alcohol involvement for major trauma patients
Background:Alcohol use is a key preventable risk factor for serious injury. To effectively prevent alcohol-related injurie...
Transition from ICD-9-CM to ICD-10-CM/PCS in Portugal: An heterogeneous implementation with potential data implications
Transition from ICD-9-CM to ICD-10-CM/PCS in Portugal: An heterogeneous implementation with potential data implications
ACSS (2016a) Implementação do Sistema de Codificação Clínica ICD-10-CM/PCS em Portugal, em substituição da atual ICD-9-C...
The diagnostic certainty levels of junior clinicians: A retrospective cohort study
The diagnostic certainty levels of junior clinicians: A retrospective cohort study
Background:Clinical decision-making is influenced by many factors, including clinicians’ perceptions of the certainty arou...
An equitable approach to enhancing the privacy of consumer information on My Health Record in Australia
An equitable approach to enhancing the privacy of consumer information on My Health Record in Australia
Australia’s national electronic health record (EHR), My Health Record (MHR), raises concerns about information privacy and...
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