How to Ensure Your Documentation Meets the MEAT Criteria
According to ICD Coding Guidelines, all conditions co-existing at the time of the encounter that require or affect patient care and management must be clearly documented and assigned a diagnosis code. Each diagnosis must be documented clearly and precisely by the physician based on the
Medical Documentation of Burn Injuries
For successful treatment of burns, adequate documentation is a major concern. Up-to-date burn injury documentation brings more challenges and requirements for practices. Emergency departments can consider outsourcing medical transcription to get accurate reports of the treatment recordings.
Studies have highlighted that although traditional paper-based documentation
Dos and Don’ts of Maintaining Good Clinical Records
Well-maintained clinical records are critical for practices to deliver quality healthcare, to maintain continuity of care, and to share information among different healthcare providers. Medical records must be accurate, and written in a professional manner. Records should also include diverse components including history, patient examination,
Physician-Patient Email Communication – Key Considerations
All physicians know that patient outcomes depend on successful communication. Open communication can help providers obtain more complete information from patients, improve the prospects of a more accurate diagnosis, and promote proper counseling, thus potentially improving patient adherence to treatment plans and health outcomes.
Advantages of Using EHR Data for Clinical Research
Data collection and management in clinical research involves gathering variables pertinent to the research hypotheses and using it to generate high-quality, reliable, and statistically sound results from clinical trials. Clinical researchers collect both primary data from surveys and interviews and secondary data from paper records
