A patient is anxious about what his therapist truly thinks about him. Does the patient have a right to review the therapist’s ...

In the health care industry, there is a common adage: If you didn’t document it, it didn’t happen. For a combination of legal, medical and billing reasons, doctors spend hours every day in front of ...

What are SOAP notes: A structured documentation method capturing subjective and objective data, assessment, and plan to ensure clarity and continuity in patient care. Why they matter: Clear SOAP notes ...

In spring 2021 a new federal rule went into effect, requiring all health care providers that maintain electronic medical records to make clinical notes and other health care information available to ...

In April, the federal government mandated that healthcare providers provide free electronic access to patients' clinical notes, as part of the 21st Century Cures Act. This includes eight types of ...

What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during ...

Most primary care providers see 15 to 20 patients a day, and many of them spend up to two hours a shift typing information into patient charts. It's a leading reason for physician burnout, said Dr.

LONDON, Feb. 12, 2026 /PRNewswire/ -- Following a successful pilot program at several NHS Trusts, Oracle Health today announced its Clinical AI Agent, Clinical Note is now available in the UK. The new ...

July 19, 2021 - The federal Open Notes Rule (the "Rule") implements a portion of the federal 21st Century Cures Act (Cures Act) related to "information blocking." It specifies that clinical notes are ...

NEW YORK CITY -- Clinical notes for patients with substance use disorder (SUD) contained stigmatizing language -- such as "junkie," "dirty user," and "this drunk" -- on a regular basis, according to a ...