For decades, provider documentation has served multiple critical functions. It’s the foundation of clinical communication, ensuring that every member of the care team has a clear, complete picture of ...

Documentation and assessments are crucial to following patients’ progress. One action research project radically changed processes to improve patient care Liz Lees MSc, Dip HSM, BSc, DipN, RGN, is ...

Clinical documentation is the written record of a patient-physician encounter. Before the advent of electronic health records (EHRs), these encounters were often inadequately documented. While this ...