Expert discusses common medical record documentation mistakes, including failing to update prepopulated or copied notes from a previous visit. I am a family nurse practitioner and, for the last few ...

The Medical Documentation Course is an online self-paced, in-depth program that focuses on patient evaluation, documentation of the encounter and its billing. Instruction is presented through ...

AI scribes are cutting physician burnout, improving documentation and expanding care access. These tools may soon become ...

Steve Claypool, MD, is vice president of clinical development and informatics, and Allison Errickson, CPC-H, is director of coding compliance and content, Clinical Solutions Division, for ProVation ...

Documentation from external sources may include educational or medical records, as well as reports and assessments created by health care providers, school psychologists, or the educational system. In ...