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 ...

Generative AI has taken over from GPs to write patients’ notes at one health centre in Weston-super-Mare. When patients at St Georges Surgery in Worle get an appointment with their doctor, instead of ...

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 ...

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 ...

Health care systems have been putting therapists’ progress reports online, much to the surprise (and anger) of some patients. By Christina Caron Stunned. Ambushed. Traumatized. These were the words ...

Physician assistant Sarah Garwood talks with Meryl Ruda during an appointment at the UNC Family Medicine at Panther Creek office Wednesday, Nov. 8, 2023. Ethan Hyman [email protected] In the ...

Doctors’ notes are meant to be an objective record of their interactions with patients. Among other uses, the notes provide important context for any other providers who treat those patients in the ...