In an effort to provide helpful information to providers, CMS has released a special edition MedLearn Matters (MLN) article that disseminates diagnosis-related group (DRG) coding vulnerabilities for ...

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 ...

Which record-keeping system is more accurate for documenting a patient's progress, paper or electronic? There were mixed results after researchers reviewed 500 progress notes written by physicians at ...

Several weeks ago, a patient of mine was admitted to the hospital. Reading through the admission notes, from the triage by the emergency department (ED) through the admitting team, I unfortunately was ...