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The patient problem list, a key component of the electronic health record (EHR), is a list of the important illnesses, injuries, and other factors impacting a patient’s health. American Health Information Management Association (AHIMA) defines the problem list as “a compilation of clinically relevant

The electronic medical record (EMR) contains a ton of information – the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, results of lab tests, and radiology images. Outsourcing medical transcription helps providers ensure up-to-date information in the EMR. Today, integration of the

The electronic health record (EHR) is designed to reduce risk of errors and help physicians make better decisions about patient care. When it comes to EHR documentation, medical transcription service providers deliver the necessary support to ensure that patient records have all the relevant

Electronic health records (EHRs) have come a long way since they were introduced and are continuing to evolve with flexible functionalities that improve the clinical decision-making process. Medical transcription services allow healthcare providers to manage the record keeping process and save time to focus

Progress notes or SOAP (Subjective, Objective, Assessment, Plan) notes, document various aspects of the patient’s treatment and highlight important issues or concerns relating to care. Good progress notes tell the patient’s story and prioritize patient care and safety. These notes provide information related to medical