Medical documentation by practicing physicians has been a challenge since the creation of the medical chart. During his years of practice, Dr. Will Carracino, chief medical information officer at ...

I recently took care of a patient whose medical records included multiple notes about her past open-heart surgery. Only she had never undergone open-heart surgery. That would have been obvious if the ...

Expert discusses common medical record documentation mistakes, including failing to update prepopulated or copied notes from a previous visit. I am a family nurse practitioner and, for the last few ...