New collaboration between QuickEMR and ScribePT brings AI-powered documentation directly into QuickEMR’s platform, ...

Editor's Note: Healthcare is serious business, and the repercussions of deficiencies in medical documentation can be considerable. Nurse attorney Carolyn Buppert examines the landscape of medical ...

Each patient has a story, and one quality of a good doctor is how that story is collected and documented in the medical record. Understanding the patient, their symptoms, and what they’ve tried is the ...

Effective use of electronic medical record technology requires examination of the communication approaches of both care providers and patients. Objective: To determine the agreement between ...

Serbin Medical Billing published guidelines for medical record documentation that apply to medical and surgical services in all settings. Ensure services billed are supported by the medical record ...

The rule standardizes the electronic exchange of medical records and other documents requested by payers to support claims.

Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Although advance care planning (ACP) in this population improves ...

To determine whether electronic health record (EHR) tools improve documentation of pre- and postanalytic care processes for genetic tests ordered by nongeneticists. We conducted a nonrandomized, ...

In the near future, Recovery Audit Contractors and Medicare Administrative Contractors (MACs) will take "appropriate action" on erroneously allowed claims identified in a recently completed audit (OEI ...