The history of the present illness should be longer than a tweet and twice as informative.  Any twitter users out there? If so, you know that 140 is the maximum number of characters, including punctuation and spacing. Why bring this up in the context of electronic health records?  Because too often, the HPI in EMR […]

“I have a normal exam template that I always use.” All right, I know baseball season is over, and it is hunting season in Vermont, so maybe I should title this, “Don’t shoot yourself in the foot.”  The government and private payers have cloned notes in their line of vision.  And, physicians and Non-Physician Practitioners […]

“My medical assistant populates the past medical, family and social history in every note.” Reading hundreds of medical records each month, I’ve come to the conclusion that less is more in physician documentation.  I’m singing a different song this year, from the one I and many other documentation specialists sang in previous years, when we […]