In the health care industry, there is a common adage: If you didn’t document it, it didn’t happen. For a combination of legal, medical and billing reasons, doctors spend hours every day in front of ...

Most primary care providers see 15 to 20 patients a day, and many of them spend up to two hours a shift typing information into patient charts. It's a leading reason for physician burnout, said Dr.

Crafting the ideal patient progress note, at least judging from the literature, seems more easily achieved in theory than in execution. Since the late 2000s, when the electronic health record replaced ...

The call to action comes when patients see their physician's notes, says Jan Walker, a registered nurse and principal associate in medicine at Beth Israel Deaconess Medical Center (BIDMC) and Harvard ...

In April, the federal government mandated that healthcare providers provide free electronic access to patients' clinical notes, as part of the 21st Century Cures Act. This includes eight types of ...

Patients overwhelmingly want access to the notes their physicians take during visits, according to one study that was recently published in the Annals of Internal Medicine. About 95 percent of ...

When patients receive services from mental health professionals (MHPs), they have a right to informed consent (Barsky, 2023). Informed consent includes the right to understand what kinds of records ...

NEW YORK CITY -- Clinical notes for patients with substance use disorder (SUD) contained stigmatizing language -- such as "junkie," "dirty user," and "this drunk" -- on a regular basis, according to a ...

Notes written about non-Hispanic Black patients had higher odds of containing terms undermining credibility and lower odds of supporting credibility compared with notes about White patients. HealthDay ...

Little is known about how racism and bias may be communicated in the medical record. This study used machine learning to analyze electronic health records (EHRs) from an urban academic medical center ...