Even though EHRs have made charting more complete and reliable, it is also time-consuming for providers. To ensure proper documentation along with provision of quality care, and to prevent stress and burnout, practices can consider optimizing systems and processes. Medical records contain diverse details such
When a doctor refers a patient to another doctor, they typically receive an order for a consultation report. The consulting doctor is an expert in a field unrelated to the one the other doctor specializes in, necessitating the need for a second opinion in
This is an update to our blog: Sharing Notes with Patients – What Physicians Need to Know
Good medical record keeping is essential for the delivery of quality healthcare and to support communication between different healthcare professionals. With the widespread adoption of electronic health
As with all other medical specialties, complete, accurate, and timely documentation is crucial in physical therapy to ensure that patients receive appropriate, efficient, individualized, and high-quality healthcare services. Physical therapists (PTs) also need to keep proper clinical records for defending a medical negligence claim
Medical record keeping has evolved over the years. Formerly, physicians dictated their notes and got the spoken reports converted into hand-written or typed notes by a medical transcription service company. With the advent of EHRs, the role of medical transcriptionists changed and they now