Expert discusses common medical record documentation mistakes, including failing to update prepopulated or copied notes from a previous visit. I am a family nurse practitioner and, for the last few ...

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 ...

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 ...

Timely and accurate completion of medical records is essential to ensuring great quality of care, as even the smallest inconsistency or miscommunication of patient information could mean negative ...

The AMA details a teamwork approach to EHR documentation that can give back doctors precious time for direct patient care.

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 ...

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.

In a study comparing junior medical interns to ChatGPT, researchers from Taipei Medical University, Taiwan, have found that while AI excels at creating accurate and complete medical records, it ...

Two thousand years ago, physicians in Egypt documented their patients’ symptoms and treatments on papyrus scrolls. These early medical records served a simple, localized purpose: they supported direct ...