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Intern Year: A Resident’s Reflections and Advice

Sensible Medicine

Also document behaviors you hope to avoid. Sometimes, this can be demonstrated by something as simple as a thorough physical exam. Emulate You will work with physicians whose practice inspires you. Write down key behaviors and traits that you observe and then strive to emulate these in your own practice.

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Friday Reflection 27: The Poor Historian

Sensible Medicine

Often, the inability of a doctor to obtain a history is actually a physical exam finding – an extremely non-specific finding, but a finding nonetheless. iii] I have had numerous people appear on my schedule with the chief concern of “chest pain” documented by the nurse.

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What Are SOAP Notes and How Do You Write Them?

Valant

Objective : Vital signs, results of physical exams, completion of inventories/instruments, and other actual observations such as the patient’s mood, behavior, appearance, and statements, when pertinent to treatment. Check out Valant’s clinical documentation features to learn more.

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Telehealth Use Among Older Americans: Growing Interest, Remaining Concerns

Health Populi

These included: A clinician’s lack of ability to conduct a physical exam (75% of older people concerned about this). But a telehealth encounter was seen as more convenient than an office visit by 56% of older people. The study identified several key concerns about telehealth visits, shown in the graphic. 24% had privacy concerns.

Follow-Up 171
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Reduce after-clinic work with these practical tips

Mobius MD

Tasks like prior authorizations, quality reporting, messaging patients, and EHR documentation often overflow into after-clinic work. MAs can give certain vaccines, enter refills in the EHR for many medications, help with documentation, educate patients, and much more. Thoughtful delegation benefits your entire team.

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Speed up your medical dictation with this simple tip

Mobius MD

Medical dictation can shave off hours of documentation time each week if you have the correct workflow. One of the simplest yet least-discussed dictation best practices is to complete your dictation while you’re still in the exam room. Recalling patient details is slow because of the time lag between visits and documentation.

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The case for dictating clinical notes during patient visits

Mobius MD

Most doctors wish they could spend less time documenting care and more time providing it. Let’s review the benefits of mobile medical dictation and help you decide if real-time dictation is the right documentation workflow for your practice. In this way, patient communication doubles as documentation time.