When is the last time your hospital, health system or organization looked at codes and clinical documentation to ensure everything was compliant with law and best practices? If revenue cycle teams are ...

Ambience Healthcare rolled out an ICD-10 clinical document integrity assistant for inpatient care, aiming to help hospitalists document more accurate clinical notes and reduce billing and coding ...

The "SOAP" -- subjective, objective, assessment, plan -- format has been in common use for decades as a way of organizing physician progress notes in medical records, but it was created during a ...

Only 18 percent of electronic inpatient progress notes are original entries by clinicians, according to a research letter in JAMA Internal Medicine. Three UC San Francisco physicians — Michael D. Wang ...

Which record-keeping system is more accurate for documenting a patient's progress, paper or electronic? There were mixed results after researchers reviewed 500 progress notes written by physicians at ...

EHR progress notes are intended to do just what they sound like — give physicians a chance to provide an updated analysis of a patient’s condition and progress. For clinicians, the laborious process ...

Phone-based AI assistant generates complete progress notes from 30-45 second voice interactions, reducing documentation time by 50% IRVING, Texas , Aug. 7, 2025 /PRNewswire/ -- Pieces Technologies Inc ...

(HealthDay News) — Internal medicine attendings and housestaff disagree on the impact of electronic health records (EHRs) on the quality of progress notes, according to a study published online July 2 ...

Despite the risks associated with copying and pasting patient information into EHRs, new research shows more than 80% of the text in progress notes is either carried over or imported by clinicians.

Health care systems have been putting therapists’ progress reports online, much to the surprise (and anger) of some patients. By Christina Caron Stunned. Ambushed. Traumatized. These were the words ...