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Leveraging Artificial Intelligence To Improve Provider Documentation In Patient Medical Records, Evangeline C. Ozurigbo
Leveraging Artificial Intelligence To Improve Provider Documentation In Patient Medical Records, Evangeline C. Ozurigbo
Walden Dissertations and Doctoral Studies
Clinical documentation is at the center of a patient's medical record; this record contains all the information applicable to the care a patient receives in the hospital. The practice problem addressed in this project was the lack of clear, consistent, accurate, and complete patient medical records in a pediatric hospital. Although the occurrence of incomplete medical records has been a known issue for the project hospital, the issue was further intensified following the implementation of the 10th revision of International Classification of Diseases (ICD-10) standard for documentation, which resulted in gaps in provider documentation that needed to be filled. Based …