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Clinical documentation News
November 18, 2020
CIOs should prepare a COVID-19 vaccine distribution plan now. Making sure immunization records are digitized and easy to access is a good first step.
February 03, 2017
A recent eye health study found that patient-reported data doesn't always get recorded in a patient's electronic health record (EHR), raising questions about the accuracy of clinical documentation. ...
June 30, 2016
From meeting new government standards to navigating EHR interoperability woes, providers have a lot on their minds. Find out how they are accommodating EHR regulations without sacrificing security.
August 21, 2015
With the heat on physician practices to prepare for the impending ICD-10 implementation date, two analysts discuss how best to avoid negative outcomes.
Clinical documentation Get Started
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The ICD-10-CM (Clinical Modification) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. Continue Reading
Computerized physician order entry (CPOE), also known as computerized provider order entry or computerized practitioner order entry, refers to the process of a medical professional entering and sending medication orders and treatment instructions ... Continue Reading
A clinical decision support system (CDSS) is an application that analyzes data to help healthcare providers make decisions and improve patient care. Continue Reading
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Most of the data in an EHR is unstructured and often ignored. Natural language processing enables healthcare providers to extract meaningful insights from this untapped resource. Continue Reading
EHR software is required for most health organizations but is available with a variety of features from different vendors. Learn which system offers what your business needs. Continue Reading
In this Q&A, KLAS population health researcher Bradley Hunter says successful population health management programs hinge on goal alignment. Continue Reading
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The ICD-10 implementation date is fast approaching, and providers should know what to expect. Here are some important facts from CMS' ICD-10 resources. Continue Reading
An EHR vendor product manager continues her discussion on why providers need to be serious about testing and budgeting when implementing ICD-10. Continue Reading
In a two-part Q&A PointClickCare ICD-10 expert, Genice Hornberger, explains what providers should do in the last phases of implementing ICD-10. Continue Reading
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Most modern EHRs document sexual identity as a fixed, binary value, but classic designations such as male and female fail to include documentation for transgender patients. Continue Reading
Marc Probst, CIO at Intermountain Healthcare, said his organization is taking strides to make population health happen, is investing heavily in data analytics, and more. Continue Reading
Providers that don't host their own imaging systems don't waive all responsibility -- they still have meaningful use and patients to satisfy. Continue Reading