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 ...

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 ...

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 ...

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.

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, ...

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 ...

SimboAlpha is a cloud-based application programming interface (API) platform that acts as a voice-based virtual doctor assistant for creating Electronic Medical Record (EMR) documentation using ...