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 ...

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 ...

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 ...

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 ...

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 ...

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 ...