Skip to main content

Improving documentation of patient acuity level using a progress note template.


AUTHORS

Grogan EL , Speroff T , Deppen SA , Roumie CL , Elasy TA , Dittus RS , Rosenbloom ST , Holzman MD , . Journal of the American College of Surgeons. 2004 9 1; 199(3). 468-75

ABSTRACT

Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications.


Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications.


Tags: