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Friday Reflection 27: The Poor Historian

Sensible Medicine

iii] I have had numerous people appear on my schedule with the chief concern of “chest pain” documented by the nurse. ” Most everyone learns at some point the factoid that 80% of diagnoses come from the medical history. A novice will take longer than an expert to extract a less accurate history.

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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. Check out Valant’s clinical documentation features to learn more. This information is shared with insurance companies to justify claims.

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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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Meeting Psychiatrists’ Technical Needs: A Practice Owner’s Guide to EHR

Valant

Customizable Note Templates The ability to create and customize templates for intake, medical history, therapy notes , and progress notes helps save time and energy. Medication Management Tools E-Prescribing is one of the most important features for psychiatry. Each gain in efficiency means more time spent with patients.

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Therapy Notes vs. Progress Notes

Valant

This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, prescription medications, etc. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment.

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How Many Hours Does A Medical Assistant Work?

ACI Medical & Dental School

Document medical histories and reason for the visit. Administrative Duties: Greet patients as they arrive, check them in, and update their medical records. Perform basic lab tests and prepare samples for external labs. Patient Communication: Provide patients with information about medications and special diets.

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9 Tips and Tricks to Streamline Your Patient Visit Workflow

Mobius MD

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.