Sensible Medicine

AUGUST 16, 2024

Second, if a diagnosis is not made on the history and physical, the patient must be educated and informed about why further testing -- some of it expensive, or uncomfortable, or invasive – is necessary. Third, because so many of our tests are neither perfectly sensitive nor specific , it is necessity for us to be Bayesians.

Tests 314

Tests Documentation Medication 314

Scrubs

MARCH 1, 2023

But she failed the National Council Licensure Exam (NCLEX) twice that same year and never took the test again. But Maria said the nurses on staff in the clinic didn’t give her the paperwork to properly document the injury. The detective reached out to one of the two nurses, who said they didn’t know Blair or anyone else in Shelbyville.

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Documentation Medication Tests 264

Sensible Medicine

OCTOBER 19, 2023

Kids were then taken away and tested. We wrote this letter and submitted it to the journal, documenting that the trial violated ethical codes. Students were told not to look backwards at the dog, but inevitably some students must have snuck a peak. In my opinion, the study was unethical. Lots of false positives and negatives.

Documentation 334

Documentation Tests Medication 334

Mobius MD

NOVEMBER 26, 2024

Popular solutions include improving documentation efficiency (a pain point for physicians) and care team coordination. Use pre-visit planning and pre-appointment lab testing to reduce time wasted on the review of follow-up results. The post What is the Quadruple Aim of healthcare?

Documentation 59

Documentation Medical Assistant Patient Experience Patient Satisfaction 59

Sensible Medicine

MAY 22, 2023

The trial tested a simple one-page prompt in the electronic health record. See screenshot: The endpoint was the proportion of patients whose chart had a documented goals of care care discussion. What’s cool about this study is that the authors’ tested whether their diversion of attention made a difference.

Tests 154

Tests Documentation Hospital Care Plan 154

Sensible Medicine

AUGUST 7, 2024

In the resulting document , the working group changed the ages at which children can be expected to reach developmental milestones. Comparison of 1967 Denver Developmental Screening Tests and 2022 CDC milestones, 75 th percentile. Let’s look at 1967 vs. 2022 for the DDST and the CDC: Table 2.

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Follow-Up Transfers Tests Documentation 300

Mobius MD

FEBRUARY 14, 2024

Augmedix was one of the early companies to use AI for ambient clinical documentation. If you’re considering using an AI medical scribe, take advantage of free trial periods to test-run several products and see which best fits your workflow. How does ambient documentation work? appeared first on Mobius MD.

Documentation 52

Documentation HIPAA Medication Patient Satisfaction 52

Health Populi

FEBRUARY 13, 2025

Health Populi’s Hot Points: Physicians have become more familiar with various AI use cases that are helping reduce administrative burden, bolster cognitive processes, and streamline scribing, documentation, and notes. As we say in patient engagement and advocacy mantras, “Nnthing about me, without me.”

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Documentation Tests Medication Patient Care 77

EvidenceCare

JANUARY 12, 2024

For admitting clinicians, the key lies in distinguishing between genuine medical necessity and social admissions, ensuring meticulous documentation and rightful reimbursement. A crucial challenge arises when what may initially appear as a social admission could genuinely be medically necessary, yet the documentation lacks precision.

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Admissions Documentation Outpatient Care Hospital 130

The Healthcare Blog

APRIL 2, 2024

Then someone discovered that the largest living thing in the world was actually the 106 acre, 47 thousand tree Pando aspen grove in central Utah, which genetic testing revealed to be a single organism. By Jeff Goldsmith Years ago, the largest living thing in the world was thought to be the blue whale.

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Tests Hospital Insurance Medication 132

Mobius MD

NOVEMBER 18, 2024

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.

Triage 52

Triage Documentation Appointments Diagnostics 52

EvidenceCare

MARCH 18, 2025

By replacing traditional pre-op visits with a digital experience, Kaiser not only improved efficiency but also reduced unnecessary testing and saved millions of dollars. Initially, the idea of eliminating pre-op visits faced skepticism, but careful testing and feedback led to a solution that worked for both clinicians and patients.

Hospital 130

Hospital Discharges Appointments Patient Safety 130

Sensible Medicine

OCTOBER 19, 2023

Kids were then taken away and tested. We wrote this letter and submitted it to the journal, documenting that the trial violated ethical codes. Students were told not to look backwards at the dog, but inevitably some students must have snuck a peak. In my opinion, the study was unethical. Lots of false positives and negatives.

Documentation 226

Documentation Tests Medication 226

Medical Gas Compliance

SEPTEMBER 16, 2021

Traditional testing, with its reams of paper, has proved insufficient. At CHT, we believe every second counts, and you shouldn’t waste time managing your documentation. One can see how this paper-based process is an invitation for inefficiency, lost time, and potential error.

Documentation 52

Documentation Time Management Tests Medication 52

Connect Care Bytes Blog

AUGUST 19, 2024

On August 25, 2024, Alberta Health Services (AHS) Connect Care will be able to deliver more clinical documents and results to specific provider locations (typically where the patient was seen, rather than a default provider address). This may affect results delivery settings for some providers. Results are always available in Connect Care.

Documentation 40

Documentation Tests 40

Mobius MD

MARCH 14, 2025

While we often focus our blog articles on streamlining clinical documentation , managing the deluge of messages in your EHR is equally important. Standardized message templates can speed up replies to common inquiries, like prescription refills and test results. Use Message Templates Dont type the same response over and over.

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Huddles/Rounds Triage Scheduling Tests 59

Serenity Nurse Aide Academy

DECEMBER 12, 2024

Technical skills are also in high demand, especially in med tech roles, where hands-on expertise in medical equipment, lab procedures, and documentation is essential. With training, trainees learn how to operate complex machinery, conduct accurate testing, and maintain meticulous records.

Medication 52

Medication Critical Thinking Communication Patient Care 52

Valant

SEPTEMBER 10, 2024

This allows practitioners to spend more time on direct client care and less time on documentation. This leads to more efficient documentation processes and better overall practice management. This integration can reduce data entry time, minimize errors, and ensure consistency across all client documentation.

Documentation 98

Documentation Diagnostics Best Practices Collaboration 98

CareerStep

JULY 19, 2024

Reviewed by Becky Byrns , CHDS, CHDP-S, CEHRS, MSK and Healthcare Documentation, Health and Wellness Program Manager at CareerStep. Precise and accurate documentation is critical in healthcare and medical transcriptionists play a vital role. The transcription key provided by the client showed the lab test and value “IB 4.4.”

Medical Terminology 98

Medical Terminology Documentation Tests Follow-Up 98

Arkenea

APRIL 10, 2025

Rather than building and maintaining a large inhouse team, businesses partner with specialized vendors to handle design, development, testing, and deployment. Quality assurance: Manual and automated testing, security audits, compliance checks. Document nonfunctional requirements such as performance, security, and compliance.

Tests 52

Tests Communication Documentation Follow-Up 52

Valant

JULY 24, 2024

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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Medical History Physical Exams Vital Signs Documentation 98

Practice Index

APRIL 10, 2025

Practices are not obliged to run blood tests, chase results or complete paperwork for treatments initiated outside the NHS, they said. Another Practice Manager we spoke to pointed to the fact that its the responsibility of the private provider to ensure the safety and suitability of the treatment theyre prescribing.

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Documentation Tests Communication Patient Care 81

Connect Care Bytes Blog

MARCH 7, 2025

PRD SRO (the read-only copy of the production environment) will be available during this outage; PRD SRO is accessible from any computer used for documenting in Connect Care regularly. DURING DOWNTIME Check with Unit Clerk/Charge Nurse to confirm processes for ordering, documentation, and patient movement.

Scheduling 40

Scheduling Unit Clerk Discharges Documentation 40

Minority Nurse

NOVEMBER 14, 2022

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

Documentation 98

Documentation Vital Signs Diagnostics Patient Safety 98

The HIPAA Journal

JULY 4, 2024

The incident was detected on June 14, 2024, and attempts were made to retrieve the documents, but it was not possible to retrieve them all. Steps have since been taken to prevent similar incidents in the future.

HIPAA 119

HIPAA Documentation Billing Insurance 119

Valant

JULY 16, 2024

This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, prescription medications, etc. Valant Can Help If you need a secure EHR that is HIPAA compliant to support all of your practice’s note-taking needs, check out Valant’s clinical documentation features.

Documentation 98

Documentation Appointments HIPAA Follow-Up 98

The HIPAA Journal

OCTOBER 29, 2024

When diagnoses are reported only using enrollees’ HRAs and HRA-linked chart reviews and there are no follow-up visits, procedures, or tests, HHS-OIG is concerned that the diagnoses may be inaccurate and therefore the payments made by the CMS may be improper. In fiscal year 2023, the CMS identified $12.7

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Follow-Up Tests HIPAA Documentation 109

The HIPAA Journal

MAY 2, 2024

The software also proves a company has made a good faith effort to comply with HIPAA by maintaining full documentation of compliance activities. Many HIPAA compliance software solutions include templates for policies and HIPAA documents, such as business associate agreements.

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Tests HIPAA Business Associate Certification 52

Sensible Medicine

AUGUST 11, 2023

iii] I have had numerous people appear on my schedule with the chief concern of “chest pain” documented by the nurse. However, contrary to a standardized test on which the medical history is presented in a paragraph of clean prose, it requires skill to obtain a medical history.

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Medical History Physical Exams Huddles/Rounds Medication 233

Valant

AUGUST 2, 2024

That includes live training sessions, self-paced learning modules, test environments, and a wide-ranging knowledgebase. User Training and Support Let’s cover two EHR support considerations for your practice’s ongoing success. Onboarding New Psychiatrists EHR vendors should offer robust training and support resources.

Billing 98

Billing Medical History HIPAA Collaboration 98

MedCerts

APRIL 30, 2024

It follows a structured curriculum that covers the following aspects of Microsoft Office: Word : Ideal word processing application, allowing you to prepare and edit documents easily. MOS training in Word equips you with advanced formatting skills, enabling you to create polished documents with tables, graphics and styles.

Certification 84

Certification Follow-Up Tests Documentation 84

ACI Medical & Dental School

JANUARY 14, 2025

Document medical histories and reason for the visit. Perform basic lab tests and prepare samples for external labs. Ensure all patient records are up to date and accurately documented. Organize Necessary Documents: Bring copies of your certifications , identification, and any other required paperwork.

Medical Assistant 52

Medical Assistant Medication Vital Signs Scheduling 52

Prism Career Institute

JANUARY 16, 2025

This exam will test everything youve learned to determine whether you are prepared to become a medical assistant. After completing the program, which takes less than one year at Prism Career Institute, you will be ready to take the Certified Clinical Medical Assistant (CCMA) exam.

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Medical Assistant Medication Sterilization Tests 52

Minority Nurse

MAY 11, 2023

Secondly, the NCLEX tests integrate processes like safety, infection control, and physiological integrity throughout the test. It ’ s not divided into pharmacology, pediatrics, and management like nursing school courses and tests. Medications and disease processes the student did not learn in class may be tested.

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Tests Best Practices Documentation Medication 98

Scrubs

APRIL 20, 2023

For instance, AI can recognize the requirement for blood tests much faster than any human can. It will eventually result in quicker test collection and fast outcomes. It will bring down the scope of human errors, for instance, administering medications and documenting patient data.

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Tests Patient Care Hospital Medication 130

Mobius MD

SEPTEMBER 16, 2024

An easy starting point is to document and assess the most common patient visit types in your clinic or department. Streamline clinical documentation When providers can manage their documentation load, they’re more likely to be on time and prepared to provide excellent patient care.

Documentation 52

Documentation Scheduling Appointments Tests 52

Connect Care Bytes Blog

JUNE 18, 2024

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.

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Documentation Tests Diagnostics 40