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.

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 ...

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 ...

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 ...

Researchers at the University of Tartu showed that large language models can identify with high accuracy why patients stop ...

A new health informatics study found that clinical care documentation results in a high prevalence of text duplication and that systemic hazards require systemic interventions to fix. Earlier this ...

The researchers found that clinician notes about Hispanic/Latino and non-Hispanic Black patients had similarly higher odds of containing terms undermining credibility and lower odds of supporting ...

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 ...