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 ...

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.

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 ...

Two recent publications issued by CMS clearly indicate that the organization is tightening its requirements for the documentation required to support medical necessity and mandated signatures on ...

Documentation is one of the most cumbersome aspects of practicing medicine. A survey published in the Journal of Graduate Medical Education which elicited responses from 1500+ medical professionals ...

According to reports, the system can summarize past diagnoses, explain laboratory values, track medications, and answer ...

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 ...

In scenario 1, the physician could have avoided a denied charge simply by noting the time spent with the patient. An internal auditor could have easily seen that the physician's documentation did not ...