Clinical documentation is more than just paperwork—it’s the backbone of safe, effective, and compliant patient care. From progress notes to discharge summaries, improving documentation practices can ...

In the evolving world of healthcare, what should the medical record -- and in particular, the 21st century progress note -- actually look like? Our notes have changed and adapted over the years, ...

An army critical care nurse, tends to a Covid-19 patient on a ventilator; a predictive AI tool could soon help doctors better understand the likelihood of key patient ...

The "SOAP" -- subjective, objective, assessment, plan -- format has been in common use for decades as a way of organizing physician progress notes in medical records, but it was created during a ...

Communication in oncology was challenging long before the emergence of the US 21st Century Cures Act. Before 2021, a growing body of evidence had demonstrated the benefits of patients' access to and ...

Accurate, timely, and patient-centered clinical documentation is key to safe, effective, and compliant healthcare. From progress notes to automated EHR integration, new strategies are helping ...