Articles related to CLINICAL DOCUMENTATION

The AMA’s CPT Editorial Panel approved a structural overhaul of maternity care coding, replacing global obstetric codes with phase-specific reporting across antepartum, labor management, delivery, and postpartum care effective January 1, 2027.

CPT code 0936T became active in January 2025 for retinal photobiomodulation, with reimbursement determined claim-by-claim and scope-of-practice limits restricting who may perform the procedure.

OpenAI introduced clinician-tailored ChatGPT capabilities for documentation, evidence synthesis, and patient education, with several major academic centers as early enterprise adopters.

A $4.5 million stroke verdict shows how a missing ‘stat’ designation and one unfollowed order can end a patient’s life and a neurologist’s career.

A physician-owned oncology group in Georgia attributed retention of women oncologists to flexible scheduling, ambient AI documentation, and ownership-model voice in operational decisions.

Across 11 AI scribe tools and 5 standardized primary care cases, AI-generated notes scored lower than human notes on every PDQI-9 quality domain, with a 23.5-point gap in an acute low back pain case.