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 ...

A patient is anxious about what his therapist truly thinks about him. Does the patient have a right to review the therapist’s ...

In April, the federal government mandated that healthcare providers provide free electronic access to patients' clinical notes, as part of the 21st Century Cures Act. This includes eight types of ...

October 1, 2012 — Primary care physicians and patients believe that allowing patients to review doctors' notes has significant benefits and few problems, according to the findings of a ...

SOAP notes are more than just paperwork—they’re essential tools for nurse practitioners to communicate effectively, ensure continuity of care, and protect against legal risks. By mastering this ...

What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during ...

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.

NEW YORK CITY -- Clinical notes for patients with substance use disorder (SUD) contained stigmatizing language -- such as "junkie," "dirty user," and "this drunk" -- on a regular basis, according to a ...

July 19, 2021 - The federal Open Notes Rule (the "Rule") implements a portion of the federal 21st Century Cures Act (Cures Act) related to "information blocking." It specifies that clinical notes are ...

LONDON, Feb. 12, 2026 /PRNewswire/ -- Following a successful pilot program at several NHS Trusts, Oracle Health today announced its Clinical AI Agent, Clinical Note is now available in the UK. The new ...

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.