Articles related to CLINICAL DOCUMENTATION

A physician associate in an understaffed emergency department diagnosed a patient’s severe back pain as sciatica after a CT scan read as normal. Five days later, a different clinician identified a perirectal abscess that had already progressed to require multiple surgeries.

The use of a BD Vacutainer Z-tube, which costs approximately $0.25 to $0.50 per tube, represents a highly cost-effective intervention, preventing contamination and potentially saving nearly $11,000 per patient.

Although 58% of nurses believe they always explain things clearly, only 7% report that their patients always hear them.

A Rhode Island court denied summary judgment in an informed consent suit after a patient developed permanent tardive dyskinesia following an intra-class antipsychotic switch.

The American College of Physicians Performance Measurement Committee reviewed the single MIPS quality measure tied to migraine and declined to support it, citing outdated guideline basis, missing exclusions, and lack of physician-level testing.

CMS finalized a four-code complexity-based structure replacing legacy radiation oncology G-codes effective January 1, 2026, consolidating image guidance and treatment delivery under codes 77387, 77402, 77407, and 77412.