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 ...
In spring 2021 a new federal rule went into effect, requiring all health care providers that maintain electronic medical records to make clinical notes and other health care information available to ...
October 1, 2012 — Primary care physicians and patients believe that allowing patients to review doctors' notes has significant benefits and few problems, according to the findings of a ...
What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during ...
Isn't it time we began embracing the simplified documentation guidelines that finally came about to ease our billing and coding woes? These pared-down Centers for Medicare & Medicaid Services ...
July 19, 2021 - The federal Open Notes Rule (the "Rule") implements a portion of the federal 21st Century Cures Act (Cures Act) related to "information blocking." It specifies that clinical notes are ...
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 ...
Development and Use of Natural Language Processing for Identification of Distant Cancer Recurrence and Sites of Distant Recurrence Using Unstructured Electronic Health Record Data Although immune ...
When health care providers enter notes into patients’ electronic health records, they are more likely to portray Black patients negatively compared with white patients, two recent studies have found.
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