Documentation

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  Subject Areas on Research

  • A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population. 
  • A Retrospective Review of the Timing of Glasgow Coma Scale Documentation in a Trauma Database: Implications for Patient Care, Research, and Performance Metrics. 
  • A Yet Unrealized Promise: Structured Advance Care Planning Elements in the Electronic Health Record. 
  • A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors. 
  • A study of parent/grandparent education for managing a febrile illness using the CALM approach 
  • A systematic review of research on religion in four major psychiatric journals: 1991-1995. 
  • A typology of advance statements in mental health care. 
  • ACC/AHA/SCAI 2014 health policy statement on structured reporting for the cardiac catheterization laboratory: a report of the American College of Cardiology Clinical Quality Committee. 
  • AIUM practice guideline for documentation of an ultrasound examination. 
  • AIUM practice guideline for the performance of an ultrasound examination of the abdomen and/or retroperitoneum. 
  • American Society for Apheresis white paper: considerations for medical staff apheresis medicine physician credentialing and privileging. 
  • American Society of Radiation Oncology recommendations for documenting intensity-modulated radiation therapy treatments. 
  • Aneurysm clip. 
  • Ascertainment of vaccination status by self-report versus source documentation: Impact on measuring COVID-19 vaccine effectiveness. 
  • Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation. 
  • Assessing Key Stakeholders' Knowledge, Needs, and Preferences for Head and Neck Cancer Survivorship Care Plans. 
  • Assessing Quality in Advance Care Planning Documentation: A Survey of Current Methods. 
  • Assessing stroke patients for rehabilitation during the acute hospitalization: findings from the get with the guidelines-stroke program. 
  • Assessing the appropriateness of ICD use "appropriately". 
  • Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study. 
  • Best Practices in Medical Documentation: A Curricular Module. 
  • CAD-RADS™: Coronary Artery Disease - Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. 
  • CONSTAX2: improved taxonomic classification of environmental DNA markers. 
  • Challenges in evaluating psychosocial interventions for Autistic Spectrum Disorders. 
  • Coronary Artery Disease - Reporting and Data System (CAD-RADS): An Expert Consensus Document of SCCT, ACR and NASCI: Endorsed by the ACC. 
  • DIG--a system for gene annotation and functional discovery. 
  • Development of a computerized assessment of clinician adherence to a treatment guideline for patients with bipolar disorder. 
  • Diarrhea: applying research to bedside practice. 
  • Digital imaging of wounds: are measurements reproducible among observers? 
  • Direct comparison of a tablet computer and a personal digital assistant for point-of-care documentation in eye care. 
  • Documentation Status and Self-Rated Physical Health Among Latinx Young Adult Immigrants: the Mediating Roles of Immigration and Healthcare Stress. 
  • Documentation of conformance to preferred practice patterns in caring for patients with dry eye. 
  • Documentation of study medication dispensing in a prospective large randomized clinical trial: experiences from the ARISTOTLE Trial. 
  • Documenting data delivery: design, deployment, and decision. 
  • Documenting or Operating: Where Is Time Spent in General Surgery Residency? 
  • Documenting presence: A descriptive study of chaplain notes in the intensive care unit. 
  • Documenting the rationale and psychometric characteristics of patient reported outcomes for labeling and promotional claims: the PRO Evidence Dossier. 
  • Educational Resources and Self-Management Support to Engage Patients in Advance Care Planning: An Interpretation of Current Practice in the US. 
  • Electronic nursing documentation as a strategy to improve quality of patient care. 
  • Ethical and Regulatory Concerns in Pragmatic Clinical Trial Monitoring and Oversight. 
  • Evaluation of a Quality Improvement Intervention to Improve Pediatric Palliative Care Consultation Processes. 
  • Factors associated with reporting results for pulmonary clinical trials in ClinicalTrials.gov. 
  • Feasibility and Acceptability of a Best Supportive Care Checklist among Clinicians. 
  • Forensic document examination and algorithmic handwriting analysis of Judahite biblical period inscriptions reveal significant literacy level. 
  • Formal error rate in a computerized obstetric medical record. 
  • Frequency of Contraception Documentation in Women With Systemic Lupus Erythematosus and Rheumatoid Arthritis Within the Rheumatology Informatics System for Effectiveness Registry. 
  • High variability in radiologists' reporting practices for incidental thyroid nodules detected on CT and MRI. 
  • Identifying and overcoming obstacles to point-of-care data collection for eye care professionals. 
  • Image-Rich Radiology Reports: A Value-Based Model to Improve Clinical Workflow. 
  • Impact of a documentation intervention on health-assessment metrics on an inpatient gynecologic oncology service. 
  • Impact of automated reporting of estimated glomerular filtration rate in the veterans health administration. 
  • Implementation of Changes to Medical Student Documentation at Duke University Health System: Balancing Education With Service. 
  • Implementing the Condensed Memorial Symptom Assessment Scale on an Inpatient Oncology Unit. 
  • Improving Oral Hygiene for Veterans With Dementia in Residential Long-term Care. 
  • Improving documentation of anticoagulation and antiplatelet recommendations after outpatientendoscopy. 
  • Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System. 
  • Inconsistencies in Colonic Tattooing Practice: Differences in Reported and Actual Practices at a Tertiary Medical Center. 
  • Increasing Nursing Documentation Efficiency With Wearable Sensors for Pressure Injury Prevention. 
  • Integrating direct electronic collection of data from patients into the process of care for eye care professionals. 
  • Integration of interdisciplinary guidelines with clinical applications: Current and future scenarios. 
  • Intracranial pressure response after pharmacologic treatment of intracranial hypertension. 
  • Joint SNMMI-ASNC Expert Consensus Document on the Role of 18F-FDG PET/CT in Cardiac Sarcoid Detection and Therapy Monitoring. 
  • Medical Student Documentation Practices and Perspectives Following the 2018 CMS Billing Guidelines. 
  • Metabolomics Standards Workshop and the development of international standards for reporting metabolomics experimental results. 
  • Methods, statistical features, and baseline results of a standardized, multicentered ophthalmologic surgical trial: the Silicone Study. 
  • My Obstetrician Got Me Fired: How Work Notes Can Harm Pregnant Patients and What to Do About It. 
  • Obstetric Ultrasound Efficiency and Accuracy Using a Protocol-Based Examination. 
  • Operating Room Delays: Meaningful Use in Electronic Health Record. 
  • Pain diaries. For providers, nuanced data; for patients, a sense of control. 
  • Patient-Centered Radiology Reporting: Using Online Crowdsourcing to Assess the Effectiveness of a Web-Based Interactive Radiology Report. 
  • Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees. 
  • Preliminary report on the use of high-fidelity simulation in the training of study coordinators conducting a clinical research protocol. 
  • Preprocedural Checklist for Magnetic Resonance Imaging Patients Undergoing General Anesthesia: A Process Improvement Plan to Enhance Reimbursement. 
  • Proposing short-term observation units for the management of decompression illness. 
  • Provider Interaction With an Electronic Health Record Notification to Identify Eligible Patients for a Cluster Randomized Trial of Advance Care Planning in Primary Care: Secondary Analysis. 
  • Quality Enhancement Research Initiative in stroke: prevention, treatment, and rehabilitation. 
  • Quality improvement initiative for chronic pain assessment and management in the nursing home: a pilot study. 
  • Quality of clinical documentation and anticoagulation control in patients with chronic nonvalvular atrial fibrillation in routine medical care. 
  • Quantifying nursing workflow in medication administration. 
  • Questioning concomitant cystoscopy coding during hysterectomy in the National Surgical Quality Improvement Program database. 
  • RTOG quality assurance guidelines for interstitial hyperthermia. 
  • Rates and Factors Associated With Documentation of Diagnostic Codes for Long COVID in the National Veterans Affairs Health Care System. 
  • Recognition of CKD after the introduction of automated reporting of estimated GFR in the Veterans Health Administration. 
  • Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography's Nomenclature and Standards Committee and Task Force for a Standardized Echocardiography Report. 
  • Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project. 
  • Reducing Preventable Surgical Cancellations: Improving the Preoperative Anesthesia Interview Process. 
  • Reliability and validity of the emergency severity index for pediatric triage. 
  • Reporting the results of diagnostic neuromuscular ultrasound: an educational report. 
  • Roadmap for Transforming Preoperative Assessment to Preoperative Optimization. 
  • Screening for critical congenital heart disease in newborns using pulse oximetry: evaluation of nurses' knowledge and adherence. 
  • Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. 
  • Sometimes determination and compromise thwart success: lessons learned from an effort to study copying and pasting in the electronic medical record. 
  • Standardized reporting guidelines for studies evaluating risk stratification of emergency department patients with potential acute coronary syndromes. 
  • State boards and impaired nurses. 
  • Structured Documentation of Home Ventilator Settings in Children: A Quality Improvement Project. 
  • Structured reporting of CT enterography for inflammatory bowel disease: effect on key feature reporting, accuracy across training levels, and subjective assessment of disease by referring physicians. 
  • Structured reporting: coronary CT angiography: a white paper from the American College of Radiology and the North American Society for Cardiovascular Imaging. 
  • Tailoring "best-of-breed" safety classification for patient fall voluntary reporting. 
  • The Association of Advance Care Planning Documentation and End-of-Life Healthcare Use Among Patients With Multimorbidity. 
  • The Biomedical Resource Ontology (BRO) to enable resource discovery in clinical and translational research. 
  • The Chicago Consensus on peritoneal surface malignancies: Standards. 
  • The Electronic Health Record and Education: Rethinking Optimization. 
  • The Istanbul Protocol: international standards for the effective investigation and documentation of torture and ill treatment. 
  • The association of indoor heat exposure with diabetes and respiratory 9-1-1 calls through emergency medical dispatch and services documentation. 
  • The rationale and development of an adult cardiac anesthesia module to supplement the society of thoracic surgeons national database: using data to drive quality. 
  • Traditional text-only versus multimedia-enhanced radiology reporting: referring physicians' perceptions of value. 
  • Trauma Surgery. 
  • Using Hourly Time-Outs and a Standardized Tool to Promote Team Communication, Medical Record Documentation, and Patient Satisfaction During Second-Stage Labor. 
  • Using PDSA cycles to improve oral care compliance. 
  • Using the Internet to teach consumers about quality care. 
  • Walking the walk…or achieving quality is harder than it seems. 
  • Washington State's Lystedt law in concussion documentation in Seattle public high schools. 
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  Keywords of People

  • Bettger, Janet Prvu, Adjunct Associate in the Department of Orthopaedic Surgery, Duke Science & Society
  • Patel, Uptal Dinesh, Adjunct Professor in the Department of Medicine, Medicine, Nephrology