Navigating the healthcare system and its processes can seem overwhelming to patients. If patients understand why their clinician recommended something, know how and when to take medications, and why they shouldn’t skip a dose—or 10—they may not feel so out of control. Sharing examination notes with patients can be helpful to many patients who struggle…
I attended medical school in the 1960s, when Dr. Lawrence Weed reinvented the medical record to organize and leverage the physician’s patient evaluation for clarity and quality of care—what he dubbed “the problem-oriented medical record.”1,2 My internal medicine house officer training at Massachusetts General placed a high value on efficient, effective medical records and communication…
A recently published research review notes physician burnout has become a crisis in the U.S. The authors describe how the added administrative tasks of electronic health records (EHRs) have contributed to the crisis, as well as how regulatory requirements and EHR platform design exacerbate the situation…
The only way to be confident your practice is performing well is to conduct periodic internal reviews of your practice operations. This allows you to familiarize yourself with the intimate details of your practice operations and identify what you are doing well and what needs improvement. Doing so will not only help your practice become…
Digitized patient records have transformed how clinicians record, understand clinical information
Are your medical records up to date and complete? Medical records should always be complete and have accurate documentation to avoid violating the Health Insurance Portability and Accountability Act or other documentation guidelines.
In order for a physician to be reimbursed for his or her services, those services must be documented. Your documentation should be able to stand on its own; it is your story of the visit. Just imagine if the news reported, “two people found dead” and nothing else. You would want to know who, when, where, and possibly why. A good news story gives all pertinent information, and your documentation should do the same.
James F. Fries, MD, harnessed computers to address big questions