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

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 ...

Did you know that as of April 2021, all patients have electronic access to their doctors’ notes from medical appointments? This increased access to information is aimed at improving patient care, as ...

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 ...

With an influx of data available at providers’ fingertips, they can readily share information with patients. Many in the medical community advocate for note sharing as healthcare becomes increasingly ...

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 ...

Patients overwhelmingly want access to the notes their physicians take during visits, according to one study that was recently published in the Annals of Internal Medicine. About 95 percent of ...

New York City-based NYU Langone Health tested artificial intelligence to see how well it can convert physician notes into accurate lay language that improved patient understanding. The study, ...

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 ...

There is wide variation of primary care physicians’ opinions on sharing their visit notes with patients, while the great majority of patients were in favor of the practice, according to a study in the ...

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 ...

SOAP notes aren’t just paperwork—they’re the backbone of clear, consistent, and effective patient care. By structuring documentation into Subjective, Objective, Assessment, and Plan, providers ensure ...