Tag: Medical records

According to legal and medical definitions, medical confirmation often involves a consulting physician validating the opinion of the attending doctor. This process is essential in healthcare to ensure accuracy, support treatment plans, and provide peace of mind to patients seeking a clear understanding of their health status.

According to the Office of the National Coordinator for Health Information Technology, a significant number of people who access their records online end up requesting corrections. Understanding what is the procedure for correcting an error in a patient's record is a crucial step in ensuring your medical information is accurate and complete.

Developed in the 1960s, the problem-oriented medical record (POMR) was designed to provide a more logical and structured approach to patient documentation. This systematic method organizes a patient's entire health information based on a specific set of problems rather than a chronological timeline. So, which information is part of a problem-oriented medical record?

Accurate and timely patient documentation is crucial for safe and effective healthcare, with up to 70% of medical communication occurring through progress notes. Learning how to write a patient progress report is therefore an essential skill for any healthcare professional, ensuring clarity and continuity in patient care.

According to a study published in JAMA Network Open, as many as 81% of patients have avoided telling a clinician medically relevant information. Knowing exactly what to do at a new patient visit is crucial for building trust and ensuring your doctor has the full picture of your health from day one.

Studies suggest that a significant percentage of medical second opinions can result in a modified or new diagnosis, leading to a changed treatment plan. Learning **how to get a second opinion from another doctor** is a proactive and essential step that empowers you to take control of your healthcare journey and gain peace of mind.

Over 85% of patients report feeling rushed during medical appointments, highlighting the need for better preparation to maximize time with a specialist. Learning how to prepare for a consultant appointment empowers you to take control of your health journey and ensure all your concerns are addressed thoroughly.

According to the Centers for Medicare & Medicaid Services (CMS), a patient is an inpatient once formally admitted via a doctor's order, distinguishing them from observation status patients who may also stay overnight. Knowing **what is the proper way to identify an inpatient** is crucial for accurate billing and appropriate medical care.

According to the Infusion Nurses Society, meticulous documentation is a standard of practice for all vascular access procedures. Our guide explores **what should be documented after IV insertion** to ensure a complete, accurate, and defensible clinical record for every patient.

According to one survey of physicians, requests for medical letters and forms for non-clinical reasons are a bi-weekly occurrence in many practices, highlighting a common patient need for documentation. Navigating this process effectively requires understanding a doctor's responsibilities, legal constraints, and the proper procedure for a successful outcome when you ask your doctor to write you a letter.