Personal and professional development activity tracking in a pharmacy curriculum.

BACKGROUND AND PURPOSE: Personal and professional development (PPD) is an essential focus of pharmacy school curriculum in developing future pharmacists. This manuscript describes the creation, implementation, and data collection of a PPD Activity Tracker in a pharmacy curriculum. EDUCATIONAL ACTIVITY AND SETTING: Previously, in "Standards 2016" and currently in "Standards 2025", colleges of pharmacy are tasked with documenting how students achieve PPD throughout their academic careers. Therefore, the PPD course directors developed a PPD Activities Tracker to provide student pharmacists a central location to document curriculum and co-curricular activities as they matriculate through the pharmacy program. The tracker was created using an electronic survey platform. Eleven activity categories were established, and students noted whether the activity was directed toward personal and/or professional development. The purpose of the tracker was to create a repository for student documentation of their PPD-promoting experiences and to provide a mechanism for individual and cohort reporting for assessment and accreditation. FINDINGS: Student pharmacists from two class cohorts entered 3254 PPD activities into the tracker over a two-year period. All PPD categories were tracked with the highest attended activities, including personal development & self-care (19%) and self-reflection (19%); the next highest category was interprofessional education/collaboration (15%). Students noted that most PPD activities enhanced their personal and professional development (49%), while personal development only and professional development only were 31% and 19%, respectively. The students "highly recommended" (72%) most tracked PPD activities, while 26% of activities were "recommended." Individual student and class cohort data were also readily accessible. SUMMARY: The PPD tracker created a central, easily accessible, and organized storehouse for successfully collecting curricular and co-curricular PPD activities throughout the student pharmacist's career. The data from this tracker could easily be collected and sorted individually as a class cohort or for an individual student pharmacist.

An assessment of narrative operative reports for Wilms tumor resection using consensus component criteria.

INTRODUCTION: Precision in surgical documentation is essential to avoid miscommunication and errors in patient care. Synoptic operative reports are more precise than narrative operative reports, however they have not been widely implemented in pediatric surgical oncology. To assess the need for implementation of synoptic operative reports in pediatric surgical oncology, we examined the completeness of narrative operative reports in patients undergoing resection of Wilms tumor. METHODS: We conducted a retrospective review of narrative operative reports for resection of Wilms tumor at a single pediatric oncology center from January 2022 through July 2023. Primary outcomes were the presence or absence of 11 key operative report components. Inclusion rates were calculated as simple percentages. Unilateral and bilateral operations were considered. RESULTS: Thirty-five narrative reports for Wilms tumor resection were included. The most consistently documented operative report components were estimated blood loss, indication for surgery, intraoperative complications, and specimen naming (100% documentation rates). Documentation of lymph node sampling was present in 94.3% of reports. The least consistently documented components were assessment of intraoperative tumor spillage, completeness of resection, metastatic disease, and assessment of vascular involvement (each ≤40% documentation rate). All 11 key components were documented in three reports. CONCLUSIONS: Even at a large tertiary pediatric oncology referral center, narrative operative reports for pediatric Wilms tumor resection were found to be frequently missing important components of surgical documentation. Often, these were omissions of negative findings. Utilization of synoptic operative reports may be able to reduce these gaps.

Hypertension evaluation and management in new young patients: are we doing our female patients a disservice?

PURPOSE: Cardiovascular disease (CVD) is one of the leading causes of death in women, largely underpinned by hypertension. Current guidelines recommend first-line therapy with a RAAS-blocking agent especially in young people. There are well documented sex disparities in CVD outcomes and management. We evaluate the management of patients with newly diagnosed hypertension in a tertiary care clinic to assess male-female differences in investigation and treatment. METHODS: Clinic letters of all new patients under the age of 51 attending the Glasgow Blood Pressure Clinic between January and December 2023 were reviewed. The primary outcomes measured were first-line treatment choices, deviations from guideline-recommended treatment, investigations for secondary hypertension, and documentation of female-specific risk factors and family planning advice. Secondary outcomes included clinical characteristics such as systolic and diastolic blood pressure at referral and at the new patient appointment, age at diagnosis, age at first appointment, and the number of antihypertensive drugs prescribed at referral. RESULTS: One hundred and five (59:46, M:F) new patient encounters were reviewed after sixteen exclusions for non-attendance and inappropriate clinic coding. Choice of first line antihypertensive agent did not vary between sexes with no deviation from guideline-recommended medical therapy. Men, however, had more biochemical investigations conducted for secondary causes across all ages. This was greatest in those under 40 years old. There was suboptimal documentation of female-specific risk factors (obstetric and gynaecological history), contraceptive drug history and family planning with 35%, 20%, and 15.6%, respectively. CONCLUSION: In 2023, women under 51 years of age seen in a tertiary care hypertension clinic received similar first-line treatment to their male peers. However, relevant female-specific histories were suboptimally documented for these patients. Whilst therapeutic approaches in men and women appear to be similar in this clinic, there are opportunities to improve CVD prevention in women, even in a specialised clinic setting.

Hypertension, or persistent high blood pressure, is a condition that can lead to serious cardiovascular diseases such as stroke and heart failure. Evidence has shown that women have cardiovascular disease more than men and it is the leading cause of death in women in Europe. To understand how male and female patients are treated for hypertension, we examined documented consultations and treatments of 105 patients under the age of 51 (46 women and 59 men) at a Glasgow hypertension clinic in 2023. We found that men had more investigations for specific causes of their hypertension across all ages (men = 88%, women = 61%). Recording of reproductive history (35%), contraceptive drug history (20%) and advice on family planning (15.6%) was not as thorough as they could be. Incorrect management of female reproductive history and contraceptive drug history can increase the risk of long-term hypertension complications, so managing this is crucial. A class of drugs commonly used to manage hypertension called RAAS blockers are dangerous to the foetus when pregnant - another factor to consider when managing young women with high blood pressure. Overall, these findings mean that there may be a need for more thorough consideration of women's health factors in hypertension treatment. By paying attention to these areas, we can enhance long-term cardiovascular health for women.

Documentation of critical intraoperative oncologic findings: Synoptic versus narrative operative reports for childhood cancer surgery.

BACKGROUND: Documentation of intraoperative oncologic findings varies greatly across narrative operative reports (NRs). An international panel of childhood cancer experts recently developed a synoptic operative report (SR) for childhood cancer surgeries. The aim of this study was to compare the documentation of critical intraoperative findings in NRs versus SRs. METHODS: A single-center retrospective review of all surgical resections of primary solid tumors at our pediatric oncology center was conducted from June 2023 to March 2024, after an institutional SR was piloted from October 2023 onwards. Data collected included the presence or absence of six components included in standard pediatric oncology NRs. Inclusion rates were calculated as percentages for each component. Due to the small sample, the Fisher's exact test was used for all hypothesis testing. RESULTS: Seventy primary tumor resections were performed during the study period, as documented by 38 NRs and 32 SRs. All operative reports after October 2023 were SRs. Completeness of tumor resection and specimen naming were consistently documented in NRs (86% and 100%, respectively) and SRs (100% and 100%, respectively). The presence/absence of three components-intraoperative tumor spillage (31%), vascular involvement (31%), and lymph node sampling (26%)-were documented in fewer than a third of the NRs. Documentation of the presence/absence of locoregional spread, intraoperative tumor spillage, vascular involvement, and lymph node sampling was significantly better in SRs than in NRs. CONCLUSION: Adoption of SRs significantly improved the documentation of critical intraoperative findings. Thus, we recommend using SRs in pediatric solid tumor surgery.

[Importance of documentation. Not documented is deemed to be not done]. / Bedeutung der Dokumentation. Nicht dokumentiert gilt als nicht gemacht.

Only a few physicians are willing to comprehensively concern themselves with how a legally watertight treatment documentation should be structured, in addition to their practical activities; however, the importance of the documentation cannot be emphasized enough, not only for a potential case of liability but also for the medical (further) treatment. This article therefore illustrates the legal foundations of the mandatory documentation and the most important questions associated with it for the practice, in particular on the content of the documentation, the timing of the documentation, the preservation of treatment documents and on the conduct in cases of an impending incident.

Disparities in Documentation: Evidence of Race-Based Biases in the Electronic Medical Record.

Personal implicit biases may contribute to inequitable health outcomes, but the mechanisms of these effects are unclear at a system level. This study aimed to determine whether stigmatizing subjective terms in electronic medical records (EMR) reflect larger societal racial biases. A cross-sectional study was conducted using natural language processing software of all documentation where one or more predefined stigmatizing words were used between January 1, 2019 and June 30, 2021. EMR from emergency care and inpatient encounters in a metropolitan healthcare system were analyzed, focused on the presence or absence of race-based differences in word usage, either by specific terms or by groupings of negative or positive terms based on the common perceptions of the words. The persistence ("stickiness") of negative and/or positive characterizations in subsequent encounters for an individual was also evaluated. Final analyses included 12,238 encounters for 9135 patients, ranging from newborn to 104 years old. White (68%) vs Black/African American (17%) were the analyzed groups. Several negative terms (e.g., noncompliant, disrespectful, and curse words) were significantly more frequent in encounters with Black/African American patients. In contrast, positive terms (e.g., compliant, polite) were statistically more likely to be in White patients' documentation. Independent of race, negative characterizations were twice as likely to persist compared with positive ones in subsequent encounters. The use of stigmatizing language in documentation mirrors the same race-based inequities seen in medical outcomes and larger sociodemographic trends. This may contribute to observed healthcare outcome differences by disseminating one's implicit biases to unknown future healthcare providers.

Video Documentation in Thyroidectomy and an Evaluation of Operative Notes.

Introduction Accurate and detailed documentation of surgical operation notes is crucial for post-operative care, research and academic purposes, and medico-legal clarity. Several studies have shown their defiency and inaccuracy sometimes, and some methods have been proposed to make them more objective. This study aimed to evaluate the completeness of thyroidectomy operative notes in a tertiary center and to assess the adequacy of video documentation by comparing it to the corresponding operative notes. Methods A retrospective review of thyroidectomy operative notes from 2010 to 2020 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, was performed to ensure completeness. Subsequently, 15 thyroidectomies were video recorded, and their notes were compared to the corresponding written operative notes. The completeness score was calculated based on an item list that included items that had to be included in an operative note. An independent samples t-test was used to compare the completeness score means between the two groups. One-way analysis of variance was used to compare the completeness score means between two or more groups. Result A total of 385 thyroidectomy-operative notes were retrospectively reviewed. The completeness scores ranged between 6% and 89% for the various items that had to be documented, with a mean of 54.47%. The mean score of the video-documented operative record was 83.86%±12.84%, which was significantly higher than the corresponding written operative notes (47.53%±18.06%) (p <0.001). Conclusion Video documentation showed significant improvement compared to the corresponding written and retrospective operative notes. Video recording can also be a valuable tool when teaching anatomy and surgical skills and conducting research.

Making Metadata Machine-Readable as the First Step to Providing Findable, Accessible, Interoperable, and Reusable Population Health Data: Framework Development and Implementation Study.

BACKGROUND: Metadata describe and provide context for other data, playing a pivotal role in enabling findability, accessibility, interoperability, and reusability (FAIR) data principles. By providing comprehensive and machine-readable descriptions of digital resources, metadata empower both machines and human users to seamlessly discover, access, integrate, and reuse data or content across diverse platforms and applications. However, the limited accessibility and machine-interpretability of existing metadata for population health data hinder effective data discovery and reuse. OBJECTIVE: To address these challenges, we propose a comprehensive framework using standardized formats, vocabularies, and protocols to render population health data machine-readable, significantly enhancing their FAIRness and enabling seamless discovery, access, and integration across diverse platforms and research applications. METHODS: The framework implements a 3-stage approach. The first stage is Data Documentation Initiative (DDI) integration, which involves leveraging the DDI Codebook metadata and documentation of detailed information for data and associated assets, while ensuring transparency and comprehensiveness. The second stage is Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) standardization. In this stage, the data are harmonized and standardized into the OMOP CDM, facilitating unified analysis across heterogeneous data sets. The third stage involves the integration of Schema.org and JavaScript Object Notation for Linked Data (JSON-LD), in which machine-readable metadata are generated using Schema.org entities and embedded within the data using JSON-LD, boosting discoverability and comprehension for both machines and human users. We demonstrated the implementation of these 3 stages using the Integrated Disease Surveillance and Response (IDSR) data from Malawi and Kenya. RESULTS: The implementation of our framework significantly enhanced the FAIRness of population health data, resulting in improved discoverability through seamless integration with platforms such as Google Dataset Search. The adoption of standardized formats and protocols streamlined data accessibility and integration across various research environments, fostering collaboration and knowledge sharing. Additionally, the use of machine-interpretable metadata empowered researchers to efficiently reuse data for targeted analyses and insights, thereby maximizing the overall value of population health resources. The JSON-LD codes are accessible via a GitHub repository and the HTML code integrated with JSON-LD is available on the Implementation Network for Sharing Population Information from Research Entities website. CONCLUSIONS: The adoption of machine-readable metadata standards is essential for ensuring the FAIRness of population health data. By embracing these standards, organizations can enhance diverse resource visibility, accessibility, and utility, leading to a broader impact, particularly in low- and middle-income countries. Machine-readable metadata can accelerate research, improve health care decision-making, and ultimately promote better health outcomes for populations worldwide.

Advantages of a Data Capture System with Video to Record Neonatal Resuscitation Interventions.

OBJECTIVE: To assess the completeness and accuracy of neonatal resuscitation documentation the electronic medical record (EMR) compared with a data capture system including video STUDY DESIGN: Retrospective observational study of 226 infants assessed for resuscitation at birth between April 2019 and October 2021 at Sharp Mary Birch Hospital, San Diego. Completeness was defined as the presence of documented resuscitative interventions in the EMR. We assessed the timing and frequency of interventions to determine the accuracy of the EMR documentation using video recordings as an objective record for comparison. Inaccuracy of EMR documentation was scored as missing (not documented), underreported, or overreported. RESULTS: Overall, the completeness of resuscitation interventions documented in the EMR was high (85-100%), but the accuracy of documentation varied between 39-100% Modes of respiratory support were accurately captured in 96-100% of the EMRs. Time to successful intubation (39%) and maximum FiO2 (47%) were the least accurately documented interventions in the EMR. Underreporting of interventions with several events (eg, number of positive pressure ventilation events and intubation attempts) were also common errors in the EMR. CONCLUSIONS: The self-reported modes of respiratory support were accurately documented in the EMR whereas the timing of interventions was inaccurate when compared with video recordings. The use of a video capture system in the delivery room provided a more objective record of the timing of specific interventions during neonatal resuscitations.

Bridging the Gap: Can Large Language Models Match Human Expertise in Writing Neurosurgical Operative Notes?

BACKGROUND: Proper documentation is essential for patient care. The popularity of artificial intelligence (AI) offers the potential for improvements in neurosurgical note-writing. The study aimed to assess how AI can optimize documentation in neurosurgical procedures. METHODS: Thirty-six notes were included. All identifiable data were removed. Essential information, such as perioperative data and diagnosis, was sourced from these notes. ChatGPT 4.0 was trained to draft notes from surgical vignettes using each surgeon's note template. One hundred forty-four surveys, with a surgeon or AI note, were shared with three surgeons to evaluate accuracy, content, and organization using a five-point scale. Accuracy was the factual correctness. Content was the comprehensiveness. Organization was the arrangement of the note. Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) scores quantified each note's readability. RESULTS: The mean AI accuracy (4.44) was not different from the mean surgeon accuracy (4.33, p = 0.512). The mean AI content (3.73) was lower than the mean surgeon content (4.42, p < 0.001). The mean AI organization (4.54) was greater than the mean surgeon organization (4.24, p = 0.064). The mean AI note's FKGL (13.13) was greater than the mean surgeon FKGL (9.99, p <0.001). The mean AI FRE (21.42) was lower than the mean surgeon FRE (41.70, p <0.001). CONCLUSION: AI notes were on par with surgeon notes in accuracy and organization, but lacked in content. Additionally, AI notes utilized language at an advanced reading level. These findings underscore the potential for ChatGPT to enhance the efficiency of neurosurgery documentation.

Accuracy of Electronic Health Record Documentation of Parental Presence: A Data Validation and Quality Improvement Analysis.

Parental presence in the neonatal intensive care unit (NICU) is known to improve the health outcomes of an admitted infant. The use of the electronic health record (EHR) to analyze associations between parental presence and sociodemographic factors could provide important insights to families at greatest risk for limited presence during their infant's NICU stay, but there is little evidence about the accuracy of nonvital clinical measures such as parental presence in these datasets. A data validation study was conducted comparing the percentage agreement of an observational log of parental presence to the EHR documentation. Overall, high accuracy values were found when combining two methods of documentation. Additional stratification using a more specific measure, each chart's complete accuracy, instead of overall accuracy, revealed that night shift documentation was more accurate than day shift documentation (76.3% accurate during night shifts, 55.2% accurate during day shifts) and that flowsheet (FS) recordings were more accurate than the free-text plan of care (POC) notes (82.4% accurate for FS, 75.1% accurate for POC notes). This research provides a preliminary look at the accuracy of EHR documentation of nonclinical factors and can serve as a methodological roadmap for other researchers who intend to use EHR data.

Implementation of major trauma app: usability and data completeness.

BACKGROUND: The current UK standard for major trauma patients is to record notes in a paper trauma booklet. Through an innovative collaboration between a major trauma centre and a digital transformation industry partner, a TraumaApp was developed. Electronic notes have been shown to have fewer errors, granular data collection and enable time stamped contemporaneous record keeping. Implementation of digital clinical records presents a challenge within the context of trauma multidisciplinary trauma resuscitation. Data can be easily accessible and shared for quality improvement, audit and research purposes. This study compared paper and electronic notes for completeness and for acceptability data following the implementation of the TraumaApp. METHODS: Trauma team members who performed scribe function attended training for the newly launched TraumaApp. Two staff members acted as scribe, using either the paper trauma booklet or TraumaApp, and attended major trauma calls. A framework for comparison of paper and electronic notes was created and used for a retrospective review of major trauma patients' notes. Statistical analysis was performed using a two-tailed t-test. Staff using the TraumaApp completed a System Usability Score questionnaire. RESULTS: There was a total of 37 data points for collection per case. The mean numbers collected were paper notes 24.1 of 37 (65.1%) and electronic notes, 25.7 of 37 (69.5%). There was no statistical significance between the completeness of paper and electronic notes. The mean System Usability Score was 68.4. DISCUSSION: Recording accurate patient information during a major trauma call can be challenging and the role of the scribe to accurately record events is critical for immediate and future care. There was no statistically significant difference in completeness of paper and electronic notes, however the mean System Usability Score was 68.4, which is greater than the internationally validated standard of acceptable usability. CONCLUSION: It is feasible to introduce digital data collection tools enabling accurate record keeping during trauma resuscitation and improve information sharing between clinicians.

Electronic documentation burden among outpatient rehabilitation therapists: a qualitative descriptive study and quality improvement initiative.

OBJECTIVES: Outpatient rehabilitation (rehab) physical, occupational, and speech therapists use electronic health records (EHR), yet their documentation experiences, including any documentation burden, are not well researched. Therapists are a growing portion of the U.S. healthcare workforce, whose need is critical to the health of an aging population. We aimed to describe outpatient rehab therapists' documentation experiences and identify strategies for mitigating any documentation burden. MATERIALS AND METHODS: We used qualitative descriptive methodology to conduct 4 focus groups with outpatient rehab therapists at Hospital for Special Surgery, a multi-site orthopedic institution. Transcripts were inductively coded to identify themes and actionable strategies for improving the therapists' documentation experiences. Therapists provided feedback and prioritization of proposed strategies. RESULTS: A total of 13 therapists were interviewed. Five themes and 10 subthemes characterize the therapists' documentation experience by a feeling that documentation inhibits clinical care and work/life balance, a perceived lack of support and efficiencies, the desire to document to communicate clinical care, and a design vision for improving the EHR. Top prioritized strategies for improvement included use of timesaving templates, expanding dictation, decluttering the EHR interface, and support for free texting over discrete data capture. DISCUSSION: Outpatient rehab therapists experience documentation burden similar to that documented of physicians and nurses. Manual data entry imposes burden on therapists' time and clinical care. CONCLUSION: A multi-faceted approach is needed for improving therapists' experiences including EHR redesign, technology supporting dictation and narrative to discrete data capture, and support from leadership and regulators.

A theoretical framework for identifying sociocultural factors that influence nurses' compliance with early warning systems for acute clinical deterioration: A cross-sectional survey.

BACKGROUND: Systematic adoption of early warning systems in healthcare settings is dependent on the optimal and reliable application by the user. Psychosocial issues and hospital culture influence clinicians' patient safety behaviours. OBJECTIVE: (i) To examine the sociocultural factors that influence nurses' EWS compliance behaviours, using a theory driven behavioural model and (ii) to propose a conceptual model of sociocultural factors for EWS compliance behaviour. DESIGN: A cross-sectional survey. SETTING: Nurses employed in public hospitals across Queensland, Australia. PARTICIPANTS: Using convenience and snowball sampling techniques eligible nurses accessed a dedicated web site and survey containing closed and open-ended questions. 291 nurses from 60 hospitals completed the survey. METHODS: Quantitative data were analysed using ANOVA or t-tests to test differences in means. A series of path models based on the theory were conducted to develop a new model. Directed or theory driven content analysis informed qualitative data analysis. RESULTS: Nurses report high levels of previous compliance behaviour and strong intentions to continue complying in the future (M=4.7; SD 0.48). Individual compliance attitudes (ß 0.29, p<.05), perceived value of escalation (ß 0.24, p<.05) and perceived ease or difficulty complying with documentation (ß -0.31, p<.05) were statistically significant, predicting 24% of variation in compliance behaviour. Positive personal charting beliefs (ß 0.14, p<.05) and subjective norms both explain higher behavioural intent indirectly through personal attitudes. High ratings of peer charting beliefs indirectly explain attitudes through subjective norms (ß 0.20, p<.05). Perceptions of control over one's clinical actions (ß -0.24, p<.05) and early warning system training (ß -0.17, p<.05) directly contributed to fewer difficulties complying with documentation requirements. Prior difficulties when escalating care (ß -0.31, p<.05) directly influenced the perceived value of escalating. CONCLUSIONS: The developed theory-based conceptual model identified sociocultural variables that inform compliance behaviour (documenting and escalation protocols). The model highlights areas of clinical judgement, education, interprofessional trust, workplace norms and cultural factors that directly or indirectly influence nurses' intention to comply with EWS protocols. Extending our understanding of the sociocultural and system wide factors that hamper nurses' use of EWSs and professional accountability has the potential to improve the compliance behaviour of staff and subsequently enhance the safety climate attitudes of hospitals. TWEETABLE ABSTRACT: A newly developed model reports nurse's personal attitudes, peer influence, perceived difficulties encountered documenting and escalation beliefs all predict early warning system compliance behaviour.

Accounting for taste: preferences mediate the relationship between documentation time and ambulatory physician burnout.

OBJECTIVES: Physician burnout in the US has reached crisis levels, with one source identified as extensive after-hours documentation work in the electronic health record (EHR). Evidence has illustrated that physician preferences for after-hours work vary, such that after-hours work may not be universally burdensome. Our objectives were to analyze variation in preferences for after-hours documentation and assess if preferences mediate the relationship between after-hours documentation time and burnout. MATERIALS AND METHODS: We combined EHR active use data capturing physicians' hourly documentation work with survey data capturing documentation preferences and burnout. Our sample included 318 ambulatory physicians at MedStar Health. We conducted a mediation analysis to estimate if and how preferences mediated the relationship between after-hours documentation time and burnout. Our primary outcome was physician-reported burnout. We measured preferences for after-hours documentation work via a novel survey instrument (Burden Scenarios Assessment). We measured after-hours documentation time in the EHR as the total active time respondents spent documenting between 7 pm and 3 am. RESULTS: Physician preferences varied, with completing clinical documentation after clinic hours while at home the scenario rated most burdensome (52.8% of physicians), followed by dealing with prior authorization (49.5% of physicians). In mediation analyses, preferences partially mediated the relationship between after-hours documentation time and burnout. DISCUSSION: Physician preferences regarding EHR-based work play an important role in the relationship between after-hours documentation time and burnout. CONCLUSION: Studies of EHR work and burnout should incorporate preferences, and operational leaders should assess preferences to better target interventions aimed at EHR-based contributors to burnout.

Leveraging AI and Machine Learning in Six-Sigma Documentation for Pharmaceutical Quality Assurance.

The pharmaceutical industry must maintain stringent quality assurance standards to ensure product safety and regulatory compliance. A key component of the well-known Six Sigma methodology for process improvement and quality control is precise and comprehensive documentation. However, there are a number of significant issues with traditional documentation procedures, including as slowness, human error, and difficulties with regulatory standards. This review research looks at innovative ways to employ machine learning (ML) and artificial intelligence (AI) to enhance Six Sigma documentation processes in the pharmaceutical sector. AI and ML provide cutting-edge technologies that have the potential to drastically alter documentation processes by automating data entry, collection, and analysis. Natural language processing (NLP) and computer vision technologies have the potential to significantly reduce human error rates and increase the efficacy of documentation processes. By applying machine learning algorithms to support real-time data analysis, predictive analytics, and proactive quality management, pharmaceutical organizations may be able to identify potential quality issues early on and take proactive efforts to address them. Combining AI and ML improves documentation accuracy and reliability while also strengthening compliance with stringent regulatory criteria. The primary barriers and limitations to the current state of Six Sigma documentation in the pharmaceutical industry are identified in this study. It examines the fundamentals of AI and ML with an emphasis on their specific applications in quality assurance and potential benefits for Six Sigma processes. The report includes extensive case studies that highlight notable developments and explain how AI/ML enhanced documentation is used in the real world.

Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs.

BACKGROUND: Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality. METHODS: Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality. RESULTS: Encounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points. CONCLUSIONS: Among outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.

Digital Documentation in Healthcare: Empowering Nurses and Patients for Optimal Care.

In response to challenges associated with extensive documentation practices within the NHS, this paper presents the outcomes of a structured brainstorming session as part of the Chief Nurse Fellows project titled 'Digital Documentation in Healthcare: Empowering Nurses and Patients for Optimal Care." Grounded in Dr. Rozzano Locsin's theory of "Technological Competency as Caring in Nursing," this project leverages a Venn diagram framework to integrate Digital Maturity Assessment (DMA) results with the "What Good Looks Like" (WGLL) Framework, the ANCC Pathway to Excellence, and the eHospital EPR program vision of University Hospitals of Leicester NHS Trust. Participants, including Clinical IT facilitators and nursing leaders, engaged in identifying synergies and gaps across digital proficiency, nursing excellence, and patient-centric care, contributing actionable insights towards an optimized digital patient care model. The findings emphasize the need for holistic digital solutions that enhance documentation efficiency, support staff excellence, and improve patient outcomes.

Efficient Workflow Analysis to Address Paper Persistence in Tuberculin Testing.

Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

Dissemination of Strategies for Reducing Excessive Documentation Burden: 25x5 Task Force Activities Relevant to Nursing.

Burnout and workforce shortages are having a negative impact on nurses globally, particularly after the COVID-19 pandemic. Within the United States, excessive documentation burden (DocBurden) has been linked to nurse burnout. The experience of a system or system-imposed process inhibiting patient care is a core focus area of nursing informatics research. The American Medical Informatics Association (AMIA) 25x5 Task Force to Reduce DocBurden was created in 2022 to decrease U.S. health professionals' excessive DocBurden to 25% of current state within five years through impactful solutions across health systems that decrease non-value-added documentation, and leverage public/private partnerships and advocacy. This case study will describe the work of the 25x5 Task Force that is relevant to nursing practice. Specifically, we will describe three projects: A) Toolkit for Reducing Excessive DocBurden, B) Development of Pulse Survey for Health Professionals Perceived DocBurden, and C) HIT Roadmap to Promote Interoperability.