Many prescriptions are now computer-generated, but may also be hand-written and paper-based. In many healthcare systems, nurses are responsible for medication transcription, which involves transferring the physician’s prescription order to the medication administration record. This must be done correctly because transcription errors, if undetected,

Accurate documentation of clinical notes is crucial for any healthcare facility’s successful running. Providers can consider relying on professional medical transcription services to create consistent and accurate documentation of recorded material. The Journal of AHIMA has stated that the main goal of documentation in healthcare

Documenting anesthesia care in the patient’s medical record accurately and thoroughly is essential to communicate the patient’s anesthetic experience. The anesthesia record should document relevant anesthesia-related information in an accurate, complete, and legible manner. Anesthesia care comprises three phases: preanesthesia, intraoperative/intraprocedural anesthesia and postanesthesia

Getting important work done in a day is every professional’s dream.  For physicians, efficient time management can ensure more time to provide quality care. When faced with a rising influx of patients with chronic conditions, flu, and other infectious diseases, making time to provide the

Transcribing operative notes, surgical reports, and other surgical documentation requires meticulous attention to detail.

Operative notes are the detailed and comprehensive documentation of a surgical procedure that is recorded by the surgical team. These notes are typically dictated by the primary surgeon or other