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Monthly Archives: December 2014

Electronic Documentation and the Role of Medical Transcriptionists

Electronic Documentation and the Role of Medical Transcriptionists

Though paper-based clinical documentation is transitioning to electronic clinical documentation, a human interface is still relevant to make the technology work optimally and that human interface already exists in the form of skilled healthcare documentation specialists as per the Association for Healthcare Documentation Integrity (AHDI). "Healthcare documentation specialist" is an umbrella term given for transcriptionists, … Continue reading Electronic Documentation and the Role of Medical Transcriptionists

Better EHR Systems and Documentation for Ebola and Other Infectious Diseases

Better EHR Systems and Documentation for Ebola and Other Infectious Diseases

With the Ebola outbreak, the efficiency of electronic health records (EHRs) in handling infectious diseases has been questioned. This October, representatives from the Centers for Disease Control (CDC) and the Office of the National Coordinator for Health IT (ONC) co-hosted a webinar to discuss the inclusion of clinical decision support tools within EHR for effective … Continue reading Better EHR Systems and Documentation for Ebola and Other Infectious Diseases

Depression Associated with CAD and CVD Risks in Younger Women

Depression Associated with CAD and CVD Risks in Younger Women

A new research found that depressive symptoms in women aged 55 and younger is associated with higher risk of coronary artery disease (CAD) and adverse cardiovascular effects (chronic CVD or cardiovascular diseases) compared to men of the same age and older women. As the study points out, depression is linked to CAD and CVD risks … Continue reading Depression Associated with CAD and CVD Risks in Younger Women

Pilot Program at Boston Hospital Provides Patients Electronic Access to Therapists’ Notes

Pilot Program at Boston Hospital Provides Patients Electronic Access to Therapists’ Notes

As electronic medical records and secure online portals grow, patients are gaining ready access not only to laboratory findings but also to clinicians’ notes. Certain health care providers with EHR systems give their patients direct access to their health information online, which enables patients to keep better track of their care, and get their questions … Continue reading Pilot Program at Boston Hospital Provides Patients Electronic Access to Therapists’ Notes

Transcribing Chart Notes in SOAP Format

Transcribing Chart Notes in SOAP Format

When an established patient is seen for a repeat visit, chart notes are dictated which include the reasons for the current visit, an assessment of the patient’s condition along with the changes since the previous visit, and additional treatment provided or planned. Chart notes are dictated in various formats such as a History and Physical … Continue reading Transcribing Chart Notes in SOAP Format

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