Here are 5 goals to consider when writing your notes: 1. Describe behavior or write down statements made by patients or family members, rather than characterizing the behavior or statement. For ...

Optimize quality management documentation for SQMS No. 1. Check out these practical tips to keep documentation appropriate ...

The state of documentation and why it’s failing IT and users Your email has been sent Because of what I do, official documentation is something I have to depend on daily. Given the bulk of my writing ...

Most clinical documentation and review is still done manually, often by clinical documentation improvement nurses, whose job it is to help patch gaps. This all leads to human errors, and even small ...

Did you know that some of the earliest “medical records” date all the way back to around 1600 BC? Those of us who have either been around long enough or know our history recognize that healthcare ...

Medicaid, like all “means-tested” programs where eligibility is based on income and assets, requires extensive documentation to establish eligibility. Proof is required to verify identity, residence, ...