Isn't it time we began embracing the simplified documentation guidelines that finally came about to ease our billing and coding woes? These pared-down Centers for Medicare & Medicaid Services ...

Encouraging patients to help write and add notes to their personal medical charts -- a task typically handled only by medical professionals -- may help patients feel more involved with their own care ...

In April, the federal government mandated that healthcare providers provide free electronic access to patients' clinical notes, as part of the 21st Century Cures Act. This includes eight types of ...

Millions of Americans may be finding that their doctors routinely refer to them with terms like SOB and BS. But patients will be better off with this knowledge, once they learn how to translate ...

In spring 2021 a new federal rule went into effect, requiring all health care providers that maintain electronic medical records to make clinical notes and other health care information available to ...

What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during ...

Please provide your email address to receive an email when new articles are posted on . Beyond its principal mission of saving lives and avoiding harm, a major priority of modern medicine is to ...

Most primary care providers see 15 to 20 patients a day, and many of them spend up to two hours a shift typing information into patient charts. It's a leading reason for physician burnout, said Dr.

More U.S. patients will soon have free, electronic access to the notes their doctors write about them under a new federal requirement for transparency. Many health systems are opening up records ...

The call to action comes when patients see their physician's notes, says Jan Walker, a registered nurse and principal associate in medicine at Beth Israel Deaconess Medical Center (BIDMC) and Harvard ...

Crafting the ideal patient progress note, at least judging from the literature, seems more easily achieved in theory than in execution. Since the late 2000s, when the electronic health record replaced ...

Health care systems have been putting therapists’ progress reports online, much to the surprise (and anger) of some patients. By Christina Caron Stunned. Ambushed. Traumatized. These were the words ...