Patients often wonder why they have to repeat information already in the chart. The answer reveals why AI may become ...

Editor's Note: Healthcare is serious business, and the repercussions of deficiencies in medical documentation can be considerable. Nurse attorney Carolyn Buppert examines the landscape of medical ...

Effective use of electronic medical record technology requires examination of the communication approaches of both care providers and patients. Objective: To determine the agreement between ...

Each patient has a story, and one quality of a good doctor is how that story is collected and documented in the medical record. Understanding the patient, their symptoms, and what they’ve tried is the ...

Effective clinical documentation improvement (CDI) programs make sure a patient’s clinical status is accurately represented in the medical record. To do this, Clinical Documentation Specialists (CDS’s ...

Serbin Medical Billing published guidelines for medical record documentation that apply to medical and surgical services in all settings. Ensure services billed are supported by the medical record ...

Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Although advance care planning (ACP) in this population improves ...

To determine whether electronic health record (EHR) tools improve documentation of pre- and postanalytic care processes for genetic tests ordered by nongeneticists. We conducted a nonrandomized, ...

To begin, the authors did not define how they quantified burnout, which is essential for reproducibility, and precludes any comparison of their findings with other results in the literature.