Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at ...

Keeping accurate documentation and nursing charts of your patients' information is sound business practice for your health care facility, doctor's office or clinic. All health care personnel should be ...

Nursing documentation is a cornerstone of contemporary healthcare, integrating systematic recording of patient observations, interventions, and outcomes with the aim of enhancing effective care ...

In light of recent allegations of gross upcoding in therapy circles, an upcoming webcast on appropriate patient evaluation and management documentation could prove popular. Alva Baker, M.D., CMD, who ...

Although emergency kits are designed to help nursing facilities provide medication to their residents during emergency situations, they can actually create more problems for facilities if not used ...

As the Cardiovascular (CV) Clinical Nurse Specialist (CNS) at The Miriam Hospital (TMH), it is my responsibility to provide for our heart failure patients. In this capacity I have been a resource to ...

Did you know that some of the earliest “medical records” date all the way back to around 1600 BC? Those of us who have either been around long enough or know our history recognize that healthcare ...

Medical records are, of course, at the core of every Recovery Audit Contractor (RAC) complex review. It's up to physicians and other providers to document the information needed to prove medical ...

Of the 120 questionnaires distributed, 103 were returned. Three questionnaires were discarded owing to excessive missing data (>30%), leaving 100 that were usable and yielding a response rate of 83%.

Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at ...