Tag Archives: Electronic Health Records

Informed Consent Documentation for Emergency Care

Though majority of procedures performed in emergency departments (EDs) do not need formal written consent, informed consent is a required process for procedures that have high risks. Documentation of informed consent is very important. If the informed consent is not … Continue reading

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Major Risks Associated with Cloud-based EHR Systems

Though cloud-based EHR systems help to access real-time patient data from multiple locations to enhance clinical documentation and are affordable, there are several risks associated with them. In an EHR system, patient documents are stored on external servers which can … Continue reading

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Changing 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

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Laryngeal 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

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Why 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

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Tele-nursing in Critical Care, The Importance of Documentation

Tele-nursing or providing medical advice via telephone is widely used in critical care as it provides an efficient, responsive and cost-effective way to access health care services. With the use of technology, tele-intensive care unit nursing can enhance available resources … Continue reading

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Documentation 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

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How Dermatologists Can Prevent Misdiagnosis of Cellulitis

A new study published in JAMA Dermatology Journal says that dermatologists have a great role to play in preventing misdiagnosis of cellulitis and overuse of antibiotics. As per the study, primary care, urgent care, hospitalist and emergency physicians often lack … Continue reading

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CDC Reports Rise in EHR Adoption Among Office-based Physicians

The US healthcare system is undergoing a massive transformation as paper-based medical charts give way to electronic health records (EHR). After nearly 25 years of using paper charts, physicians have widely started accepting the use of Electronic Health Records (EHR). … Continue reading

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Nurses and PAs Can Ease Rheumatology Workforce Shortage

A workforce study of rheumatology in the U.S. was conducted recently and it was revealed that the high demand for rheumatology services will cause a shortage of rheumatologists in the next several decades. A group of American researchers administered a … Continue reading

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