AIMC Topic: Documentation

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Exploring Suitability of Low-Severity Rating Hospital Incident Reports for Machine Learning.

Computers, informatics, nursing : CIN
Electronic incident reporting is a key quality and a safety process for healthcare organizations that assists in evaluating performance and informing quality improvement initiatives. Although it is mandatory for high-severity incident reports to be i...

Documentation, Coding, and Billing for Neurologic Services and Procedures.

Seminars in neurology
Documentation, coding, and billing (claims submission) are foundational to neurologic practice in the United States, enabling accurate reimbursement, effective communication, and data-driven advancements in patient care, research, and education. Neur...

Artificial intelligence based assessment of clinical reasoning documentation: an observational study of the impact of the clinical learning environment on resident documentation quality.

BMC medical education
BACKGROUND: Objective measures and large datasets are needed to determine aspects of the Clinical Learning Environment (CLE) impacting the essential skill of clinical reasoning documentation. Artificial Intelligence (AI) offers a solution. Here, the ...

Impact of using an AI scribe on clinical documentation and clinician-patient interactions in allied health private practice: perspectives of clinicians and patients.

Musculoskeletal science & practice
BACKGROUND: The burden associated with clinical documentation can negatively impact patient care and job satisfaction amongst allied health professionals (AHPs). Digital scribes based on artificial intelligence (AI) may address these issues, but this...

Controlled Pilot Intervention Study on the Effects of an AI-Based Application to Support Incontinence-Associated Dermatitis and Pressure Injury Assessment, Nursing Care and Documentation: Study Protocol.

Research in nursing & health
Artificial Intelligence (AI)-based applications have significant potential to differentiate between pressure injuries (PI) and incontinence-associated dermatitis (IAD), common challenges in nursing practice. Within the KIADEKU overall project, we are...

Enhancing Accuracy of Operative Reports with Automated Artificial Intelligence Analysis of Surgical Video.

Journal of the American College of Surgeons
BACKGROUND: The creation of operative reports is a tedious documentation task that increases administrative burden, which is a potential driver of burnout. Additionally, operative reports are inherently subjective and may contain inaccuracies and inc...

Assessing Patient-Reported Satisfaction With Care and Documentation Time in Primary Care Through AI-Driven Automatic Clinical Note Generation: Protocol for a Proof-of-Concept Study.

JMIR research protocols
BACKGROUND: Relisten is an artificial intelligence (AI)-based software developed by Recog Analytics that improves patient care by facilitating more natural interactions between health care professionals and patients. This tool extracts relevant infor...

Identifying Patient-Reported Outcome Measure Documentation in Veterans Health Administration Chiropractic Clinic Notes: Natural Language Processing Analysis.

JMIR medical informatics
BACKGROUND: The use of patient-reported outcome measures (PROMs) is an expected component of high-quality, measurement-based chiropractic care. The largest health care system offering integrated chiropractic care is the Veterans Health Administration...

[Structured reporting in otorhinolaryngology].

HNO
Structured reporting (SR) is a valuable method for optimizing diagnosis and treatment in various specialist disciplines. While conventional free-text findings are often inconsistent and difficult to compare, structured documentation enables higher qu...

Artificial Intelligence (AI) - Powered Documentation Systems in Healthcare: A Systematic Review.

Journal of medical systems
Artificial Intelligence (AI) driven documentation systems are positioned to enhance documentation efficiency and reduce documentation burden in the healthcare setting. The administrative burden associated with clinical documentation has been identifi...