Journal of general internal medicine
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Documentation is a key component of practice, yet few curricula have been published to teach trainees proper note construction. Additionally, a gold standard for assessing note quality does not exist, and no documentation assessment tools integrate with established competency-based frameworks. ⋯ The ANAT assesses individual components of a note, incorporates billing criteria, targets note "bloat," allows for narrative feedback, and provides global assessments mapped to the ACGME milestone framework. The ANAT can be used to assess admission notes by any attending and at any time after note completion with minimal rater training. The ANAT allows programs to implement routine note assessment for multiple functions with the use of a single tool.
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Observational Study
Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study.
National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED). ⋯ Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.