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Beyond Dictation: Emerging Trends in Physician Documentation

Mobius MD

Have you ever wondered what clinical documentation will look like in 20 years? Then again, if youre like most doctors, youre probably too busy catching up on EHR notes to think about emerging trends in physician documentation. Until recently, technology has improved documentation incrementally.

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Friday Reflection 35: Four Who Fired Me

Sensible Medicine

This doesn’t mean snake oil and unnecessary tests and referrals. After our third disagreement over her wanting preventative medications and screening tests far out of line with guidelines -- and my own comfort – she decided she’d be better served by another physician. We also spoke on the phone about every two weeks.

Tests 283
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How Physicians Can Use AI to Streamline Their Work

Mobius MD

Specifically, we’ll discuss how AI can: Automate Clinical Documentation Support Clinical Decision-Making Triage Patient Communication Diagnose Medical Images Automate Routine Tasks Each topic includes a Software Spotlight, highlighting practical tools that illustrate AI’s impact in real-world settings.

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Risks Facing Nurse Practitioners Today

Minority Nurse

Contributing factors for these diagnosis-related claims included the failure of an NP to order a diagnostic/lab test to establish a diagnosis, failure to obtain a complete history and physical of the patient, and failure to refer a patient to higher level care. The NP photographed the wound, documented that it was 0.5

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Friday Reflection 24: I Would Rather Go Back in Time

Sensible Medicine

He had also had had a normal stress test a couple of years before. My work up was extensive including imaging, blood tests, and biopsies. Knowing what I know now, and having the diagnostic tools that now exist, could I have saved her? ” I documented those words in my progress note that day.

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Should You Use Wiley Treatment Planners?

Valant

This allows practitioners to spend more time on direct client care and less time on documentation. The planners’ reference format incorporates options based on DSM-5 diagnoses, staying current with updated diagnostic codes and criteria. This leads to more efficient documentation processes and better overall practice management.

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PHI Exposed in Cyberattacks on Gaia Software & Pinnacle Orthopaedics & Sports Medicine Specialists

The HIPAA Journal

Pinnacle said the types of information involved vary from individual to individual and may include names, dates of birth, medical/health information, treatment/diagnostic information, health insurance information, and/or billing/payment information. Those individuals will be notified when the investigation is completed.

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