Remove Documentation Remove Medical History Remove Tests
article thumbnail

Friday Reflection 27: The Poor Historian

Sensible Medicine

iii] I have had numerous people appear on my schedule with the chief concern of “chest pain” documented by the nurse. ” Most everyone learns at some point the factoid that 80% of diagnoses come from the medical history. A novice will take longer than an expert to extract a less accurate history.

article thumbnail

What Are SOAP Notes and How Do You Write Them?

Valant

The information recorded may include symptoms, medical history, test results, diagnoses, treatment plans, prescription medications, and progress made at appointments. Check out Valant’s clinical documentation features to learn more. This information is shared with insurance companies to justify claims.

Insiders

Sign Up for our Newsletter

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

article thumbnail

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.

Triage 52
article thumbnail

Meeting Psychiatrists’ Technical Needs: A Practice Owner’s Guide to EHR

Valant

Customizable Note Templates The ability to create and customize templates for intake, medical history, therapy notes , and progress notes helps save time and energy. Medication Management Tools E-Prescribing is one of the most important features for psychiatry. Each gain in efficiency means more time spent with patients.

Billing 98
article thumbnail

In Demand Career Spotlight: Pediatric Medical Assistant

ACI Medical & Dental School

The day-to-day responsibilities of a Pediatric Medical Assistant can vary depending on the specific medical office or clinic, but typically include: Clinical Tasks: These involve taking vital signs, administering medications and vaccines, assisting with medical examinations, and performing simple laboratory tests.

article thumbnail

Therapy Notes vs. Progress Notes

Valant

This covers information such as diagnosis, symptoms, medical history, test results, treatment plan, progress at appointments, prescription medications, etc. Progress notes, on the other hand, record information relevant to the patient’s treatment and response to treatment.

HIPAA 98
article thumbnail

How Many Hours Does A Medical Assistant Work?

ACI Medical & Dental School

Document medical histories and reason for the visit. Administrative Duties: Greet patients as they arrive, check them in, and update their medical records. Perform basic lab tests and prepare samples for external labs. Patient Communication: Provide patients with information about medications and special diets.