Crafting the ideal patient progress note, at least judging from the literature, seems more easily achieved in theory than in execution. Since the late 2000s, when the electronic health record replaced ...

Several weeks ago, a patient of mine was admitted to the hospital. Reading through the admission notes, from the triage by the emergency department (ED) through the admitting team, I unfortunately was ...

Among the 11,046 patients who were hospitalized at Kagawa University Hospital (KUH) from January to December 2021, those who were admitted to the Gastroenterology Department as their main department ...

When patients receive services from mental health professionals (MHPs), they have a right to informed consent (Barsky, 2023). Informed consent includes the right to understand what kinds of records ...

The "SOAP" -- subjective, objective, assessment, plan -- format has been in common use for decades as a way of organizing physician progress notes in medical records, but it was created during a ...

Physician progress notes are vital for documenting patient history and treatment plans [1]. In the neonatal intensive care unit (NICU), progress notes often dually serve as a comprehensive record of ...

Three quarters of trusts in England that responded to a survey by The BMJ are still reliant on paper patient notes and drug charts, despite progress towards electronic records and prescribing. The ...