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In the U.S., federal and state laws require that every health care provider establish and maintain an accurate medical record for each patient. The HIMSS says that, “Regardless of format, whether paper, hybrid, or electronic, the medical record must meet the requirements of the

Electronic health records (EHRs) are designed to ensure accurate, current, and complete information about patients at the point of care. Physicians and nurses are always encouraged to perform medical charting as close to the patient as possible. Real-time data refers to the recording of

Mental health progress notes refer to notes that psychologists, therapists, clinical counselors, psychiatrists, and other practitioners create at each session about the patient’s clinical status. When maintaining mental health records, clinicians need to consider patient needs, legal requirements, ethical standards, and other factors.These notes include

Radiology imaging technique is widely used in almost all healthcare specialities to diagnose diseases and conditions. These diagnostic images have to be interpreted by the radiologist and transcribed into accurate radiology transcripts, which are later forwarded to the physician to decide on the treatment

New and innovative technologies are constantly transforming the medical industry and improving processes in medical practices. Many developments have led to better patient care and enhanced patient safety. One of the clear signs of this transformation are the developments witnessed in medical transcription. Medical