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 ...

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 ...

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 ...

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.

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 ...

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.