How should the patient's response to treatment be documented? How should referrals to specialists be documented, including the reason for referral?

This section provides implementers with important definitions, requirements, and guidance on creating, using, and sharing Clinical Notes. Clinical notes will make it easier to keep track of a patient's oral health history. A long view into your patient's preventative care, problems, and procedures ... Mar 10, 2020 ... SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way ... Jul 27, 2022 ... In this study, we investigate the level of implicit race information available to ML models and human experts and the implications of model-detectable ... Review the supervisee's progress notes, process notes, and other patient treatment records, as deemed appropriate by the supervisor. • With the client's ... Aug 17, 2021 ... Quoting patients may imply skepticism or convey disrespect, and we have found that the use of quotes differs by patient race and gender. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. What is CDI? Clinical documentation improvement is the process of carefully scanning a patient's medical records to make sure that their condition and all ... The Laser and Health Academy (LA&HA) is a not-for-profit organization, originally established by Fotona d.d., dedicated to the advancement and education of ... Jan 6, 2023 ... The relatively limited amount of clinical data available for NLP has been cited as a significant barrier to the field's progress. Here we ...