Why it matters: Accurate, timely documentation ensures quality care, supports legal compliance, and protects against dangerous patient outcomes. Core principles: Completeness, accuracy, objectivity, ...
Communication about end-of-life care between healthcare providers and patients is inadequate, according to a study in JAMA Internal Medicine. Researchers conducted in-person questionnaires of elderly ...
The American Medical Informatics Association this week published the results of a new report it hopes will help move the needle on the widespread problem of excessive clinical documentation burden.
Clinical documentation is the written record of a patient-physician encounter. Before the advent of electronic health records (EHRs), these encounters were often inadequately documented. While this ...
Going forward, it will be important to determine how clinicians can be trained to add value to patient care that goes beyond what ambient documentation systems can provide. Moving Beyond Efficiency In ...
Please provide your email address to receive an email when new articles are posted on . Social workers helped double advance care planning documentation among older adults with cancer. Population ...
Nurses are the cornerstone of patient care, but too often, their time is consumed by documentation. Hunt Regional Medical Center (HRMC) in Greenville TX found a promising solution to ease nurse ...
A patient is anxious about what his therapist truly thinks about him. Does the patient have a right to review the therapist’s ...
A recent lawsuit filed in San Diego Superior Court alleges that Sharp HealthCare recorded conversations between doctors and their patients without written consent, using the information to document ...
Q: What’s new with wound care documentation and CMS guidelines? A: The Center for Medicare & Medicaid Services recently issued modifications in Local Coverage Determinants that can potentially affect ...
Hosted on MSN
Mastering documentation for better patient care
From therapy informed consent to standardized clinical notes, quality documentation is the backbone of ethical, effective healthcare. It safeguards patients, supports providers, and ensures compliance ...
Some results have been hidden because they may be inaccessible to you
Show inaccessible results