Author Archives: Julie Clements
Transcribing Chart Notes in SOAP Format
Chart notes are dictated in various formats such as a History and Physical Examination (H&P) report with similar headings and less depth, as a single paragraph with few sentences, or using SOAP format. Most physicians rely on medical transcription services … Continue reading
Read MoreChanging Role of Medical Transcriptionists with EHR Implementation
The pressure for EHR (Electronic Health Record) adoption is increasing, thanks to the incentives assured and warnings of reimbursement cuts. Though electronic clinical documentation is said to reduce the relevance and significance of medical transcription, the truth is that EHR … Continue reading
Read MoreLaryngeal Cancer Surgery – Why Proper Documentation is Vital
Surgery is a commonly used treatment option for patients with laryngeal cancer. However, the effectiveness of this option depends also on proper surgical documentation. Though there are different surgical operations used to remove the cancer (for example, laser surgery, laryngectomy, … Continue reading
Read MoreWhy Documentation of Vital Signs in Emergency Departments Should Be Consistent
Though the monitoring of vital signs (heart rate, respiratory rate, temperature, blood pressure, peripheral oxygenation and pain) is a commonly performed task in emergency departments (EDs), there are no published standards of care that provide appropriate guidelines for the frequency … Continue reading
Read MoreGoogle’s Patient-Doctor Video Chat Service to Facilitate Virtual Office Visits
Google is reportedly testing a service that connects patients with doctors over a video chat, across a limited number of users. As per the Verge report, when people search for basic health information (for example, knee pain), a blue icon … Continue reading
Read MoreDocumentation Crucial for OT Interventions in Autistic Children
Different occupational therapy (OT) interventions including physical activities, play activities, developmental activities and adaptive activities can help autistic children perform better in school and home environments. However, occupational therapists should keep their documentation accurate, comprehensive and complete to ensure appropriate … Continue reading
Read MoreNeed for a Patient-centric Approach When Writing Pathology Reports
Patient-centered care (sharing the management of an illness between the patient and the doctor) in general is very important for effective healthcare as it will increase adherence to management protocols, reduce morbidity and improve the quality of life of patients. … Continue reading
Read MoreSecond MERS Case Reported in Florida
The officials from the US Centers of Disease Control and Prevention and the Florida Department of Health have confirmed on May 12, 2014, the second imported case of Middle East Respiratory Syndrome (MERS) in the United States. The second U.S. … Continue reading
Read MoreDecoding and Recording Facial Expressions
Can the vast range of our facial expressions be recorded for the computer to understand? Well, researchers are trying for sure and they could be nearly there. A Ohio State University research team has apparently managed to teach computers to … Continue reading
Read MorePharmacists in Emergency Rooms Reduce Medication Errors
Medication errors can happen in all clinical settings. However, the busy environment and fast-paced care offered in the emergency room (ER) in hospitals enhance the probability of errors. No matter how trained and experienced the emergency room physicians may be, … Continue reading
Read More