Most primary care providers see 15 to 20 patients a day, and many of them spend up to two hours a shift typing information into patient charts. It's a leading reason for physician burnout, said Dr.

In the health care industry, there is a common adage: If you didn’t document it, it didn’t happen. For a combination of legal, medical and billing reasons, doctors spend hours every day in front of ...

Crafting the ideal patient progress note, at least judging from the literature, seems more easily achieved in theory than in execution. Since the late 2000s, when the electronic health record replaced ...

The call to action comes when patients see their physician's notes, says Jan Walker, a registered nurse and principal associate in medicine at Beth Israel Deaconess Medical Center (BIDMC) and Harvard ...

A new health informatics study found that clinical care documentation results in a high prevalence of text duplication and that systemic hazards require systemic interventions to fix. Earlier this ...

Viewers of outpatient dermatology clinic notes vary widely by race, sex and economic background, suggesting that broader ...

When health care providers enter notes into patients’ electronic health records, they are more likely to portray Black patients negatively compared with white patients, two recent studies have found.

When patients receive services from mental health professionals (MHPs), they have a right to informed consent (Barsky, 2023). Informed consent includes the right to understand what kinds of records ...