Epic has rolled out AI Charting, a built-in tool that listens during patient visits and drafts clinicians’ notes and suggested orders in real time. The feature is part of Epic’s expanding set of AI ...

Clinical notes have always been a standard for creating narratives that get claims paid because they support the necessity for the services rendered. "If it isn't written, it didn't happen" still ...

To submit a legal/professional nursing question for future consideration, write to the editor at syox@medscape.net (Include "Ask the Expert" in subject line.) Until 6 months ago, I was practicing in a ...

HARRISBURG, Pa. — Doctors see thousands of patients every year and every conversation is critical. The notes they take are just as important. "A majority of our time is spent in documentation, working ...

One of the most important yet laborious components of a medical visit for a provider is chart documentation: What is the patient’s concern? What are the provider’s observations and recommendations?