Background: Medical records, encompassing patient histories, progress notes, and more,
play a crucial role in patient care and treatment, healthcare communication, medico-legal …

Background Previous studies have assessed note quality and the use of electronic medical
record (EMR) as a part of medical training. However, a generalized and user-friendly note …

Introduction Physicians recognize the importance of clinical documentation for accuracy of
coding and billing, but it is emphasized little in residency curricula, with an even smaller …

Objective The accurate documentation of a medical history interview is an important goal in
medical education. As students' documentation of medical history interviews is mostly …

As a senior pulmonary critical care fellow, my first night moonlighting in the intensive care
unit (ICU) played out like a greatest hits compilation. A formulaic central line placement, a …

Objective Discrepancies in medical coding can negatively impact institutional revenue and
result in accusations of medical fraud. The objective of the present study was to …

Medical coding and billing errors are avoidable problems that have afflicted practitioners for
decades. Correct coding and billing are required for reimbursement of healthcare services …

Rationale, aims and objectives: Since the widespread implementation of electronic medical
records, there have been concerns about errors, excessive copying forward, and reduced …

Optimal clinical documentation in the inpatient setting must not only articulate medical
decision making and communicate clinical plans but also accurately detail clinical …