Sensible Medicine
JULY 15, 2025
We often confuse healthcare documentation with healthcare delivery. The level of intimacy captured at scale might be unprecedented in human voice communication. Abridge recently introduced a Contextual Reasoning Engine that generates structured data, including predicted diagnoses, orders, and billing-ready documentation.
Mobius MD
JANUARY 9, 2025
Have you ever wondered what clinical documentation will look like in 20 years? Then again, if youre like most doctors, youre probably too busy catching up on EHR notes to think about emerging trends in physician documentation. Until recently, technology has improved documentation incrementally.
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We Care Online
DECEMBER 11, 2024
Documentation and Record-Keeping: Best practices for documenting medication administration accurately and maintaining patient records. Proper documentation is crucial for continuity of care and legal compliance. Clear communication can empower patients and improve adherence to their medication regimen.
Valant
NOVEMBER 7, 2024
Clinical Documentation Electronic health record (EHR) tools designed for behavioral health can streamline clinical workflows , freeing up more time. These systems offer note-taking features and customizable templates that simplify documentation. By adopting EHR tools, therapists can minimize the stress.
Sensible Medicine
MAY 30, 2025
He encouraged me to document clinic visits in notes that I’d be comfortable with my patients reading. When I document about a patient, I am writing about a person. Tom Delbanco was the chief of General Internal Medicine while I was there and was already advocating that patients have access to their medical records.
Northwest Career College
JULY 3, 2025
Accurate documentation is essential for medical billing and coding, but many beginners struggle to understand the technical terms and guidelines. Without accurate medical documentation, insurance claims can be delayed or denied, frustrating patients and physicians. What is Medical Documentation?
Minority Nurse
NOVEMBER 12, 2024
If a patient suffers adverse outcomes and lacks documented informed consent, NPs could face liability claims for failing to provide adequate information. Therefore, establishing clear communication and maintaining thorough documentation is essential. Documentation. Malpractice Insurance.
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