Clinical documentation comprises all the information relating to each patient’s encounters with a healthcare facility. This information is entered in the medical record by a member of the patient’s healthcare team – a physician, nurse, therapist, dentist or other healthcare professional. Chronologically documenting this
In healthcare companies, the value of complete and accurate medical records has always been recognized. Medical records give physicians a complete picture of a patient’s medical history so they have everything they need to know when diagnosing or treating a patient. The patient’s health is
Clinical documentation is the capture of clinical information at the patient encounter. Clear, accurate, consistent, complete, timely, and legible clinical documentation is necessary to reflect the patient’s condition and provide evidence that the care rendered was meaningful and medically necessary. Behavioral health providers, for instance,
Automation has disrupted many industries, and improved productivity by doing away with tasks that involve a high level of physical work and repetitive tasks. Healthcare is also benefiting from automation. One of the most common examples of automation in healthcare the development of voice
A medical report provides a detailed account of a patient’s medical history, current condition, and treatment plan. Medical reports can be written by a variety of healthcare professionals, including doctors, nurses, and therapists, involved in a patient’s care. These reports help them track the