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Beyond Dictation: Emerging Trends in Physician Documentation

Mobius MD

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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How Physicians Can Use AI to Streamline Their Work

Mobius MD

Specifically, we’ll discuss how AI can: Automate Clinical Documentation Support Clinical Decision-Making Triage Patient Communication Diagnose Medical Images Automate Routine Tasks Each topic includes a Software Spotlight, highlighting practical tools that illustrate AI’s impact in real-world settings.

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Risks Facing Nurse Practitioners Today

Minority Nurse

Contributing factors for these diagnosis-related claims included the failure of an NP to order a diagnostic/lab test to establish a diagnosis, failure to obtain a complete history and physical of the patient, and failure to refer a patient to higher level care. The NP photographed the wound, documented that it was 0.5

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Should You Use Wiley Treatment Planners?

Valant

This allows practitioners to spend more time on direct client care and less time on documentation. The planners’ reference format incorporates options based on DSM-5 diagnoses, staying current with updated diagnostic codes and criteria. This leads to more efficient documentation processes and better overall practice management.

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PHI Exposed in Cyberattacks on Gaia Software & Pinnacle Orthopaedics & Sports Medicine Specialists

The HIPAA Journal

Pinnacle said the types of information involved vary from individual to individual and may include names, dates of birth, medical/health information, treatment/diagnostic information, health insurance information, and/or billing/payment information. Those individuals will be notified when the investigation is completed.

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What Are SOAP Notes and How Do You Write Them?

Valant

The information recorded may include symptoms, medical history, test results, diagnoses, treatment plans, prescription medications, and progress made at appointments. Plan : Further diagnostic tests and other tasks are included here, along with proposed treatment including patient education, medications, further therapy, and so on.

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Update on Results Release in MyAHS Connect

Connect Care Bytes Blog

Starting June 18, 2024, five additional test results and their results-related documents will become immediately available to patients in MyAHS Connect (MAC) , the online patient tool for Connect Care, without a 5-day hold.