The clinical burden of documentation


The purpose of clinical documentation is to efficiently communicate critical data to peers in a readable fashion while meeting compliance and billing requirements. This documentation should not represent a data dump. Physicians continually increase our dependence on technology as the digital age deluges us with data. Accessing the right information at the right time is […]. Find jobs at Careers by Search thousands of physician, PA, NP, and CRNA jobs now.

5 Best Medical Document Management Services

Electronic Health Reporter

As digitalization increases day by day the management of digital documents becomes easy. The creation and distribution of digital documents have become faster than physical documents. For documents management, there are so many companies available […].


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Insights Into EHR Documentation Workstations

Healthcare IT Today

One of the most important and least covered things in healthcare IT is the various EHR Documentation Workstations.

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FHIR Document Digital Signatures

Healthcare Exchange Standards

I was asked about Digital Signatures for FHIR documents: I am working on __ IG that is FHIR document based and we need a means to prove authenticity. The model is relatively simple in that a document and all of its parts represent a single thing that needs to be “signed”.


The Future of Documents


More and more organizations are looking to de-clutter their workspaces by digitizing important documents. It’s time to look towards the future of documents. In the future, the critical data trapped behind these documents will be unleashed.


Ambient Clinical Voice, NLP, and EHR Auto Documentation

Healthcare IT Today

This shouldn’t come as a surprise since if ambient clinical voice is effective, then it could solve so many of the EHR documentation features that put such a burden on physicians in healthcare.

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Can Performance Analytics Impact the EHR Clinical Documentation Conundrum?

Healthcare IT Today

Of these, one of the top issues reported by physician users in virtually every EHR usability study is clinical documentation. The following is a guest article by Michael Clark, CEO at DeliverHealth.

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eSignatures and Digital Documents Matter Even More in a Post-COVID World

Healthcare IT Today

Healthcare IT Hospital - Health System IT IT Infrastructure and Dev Ops credentialing Deboshree Sarkar DeeDee Kato digital documents DocuSign e-signatures electronic documents eSignature Foxit Software Healthcare Scene Featured Healthcare Workflow paper processes Peter Urbain

The Auto Documentation Telehealth Solution Will Be a Big Winner

Healthcare IT Today

Last week I started a project to create a list of all of the telehealth options out there. Mostly, I wanted to be able to provide my friends and readers answer to the question I’m certain to get over the next year, “Which telehealth solution is best?”

'Much bigger than just a global pandemic': How hospitals can plan crisis EHR documentation

Mobi Health News

In a preview of their HIMSS22 panel, Serena Bumpus of Ascension and Stephanie Hoelscher of the Texas Tech University Health Sciences Center explain their Texas pilot study on crisis documentation during COVID-19 surges and how it could lessen the burden on nurses

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EHR Auto Documentation is Great, but Augmenting Doctors Is the Future

Healthcare IT Today

AI/Machine Learning Ambulatory C-Suite Leadership Communication and Patient Experience EMR-EHR Healthcare IT Hospital - Health System LTPAC Ambient Clinical Intelligence Ambient Clinical Voice Augmenting Doctors Casual AI Listener EHR Auto Documentation EHR Documentation Physician Education

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When is a document not a Document but still a document?

Healthcare Exchange Standards

Documents have a bad perception, they are big, unfocused, and hard to process or view. I'm going to propose something that is counter to the perception, driven by current healthcare use of CDA documents and the HL7 Principles of a Document. Something supported by IHE Document Sharing (XDS/XDR/XDM/XCA/MHD), something enabled and using #FHIR. When is a Document a Document? The the most important part is the HL7 defined Principles for a Document.


Taking The Sting Out of Patient Care Documentation

Electronic Health Reporter

The article Taking The Sting Out of Patient Care Documentation appeared first on Editorial healthcare documentation HEDIS IKS Health MIPS patient care documentation Shane PengThis article is copyrighted strictly for Electronic Health Reporter. Illegal copying is prohibited. By Shane Peng, MD, chief clinical services and innovations Officer, IKS Health.


Nuance Communications acquires AI clinical documentation startup Saykara

Mobi Health News

Saykara's founder and team will be augmenting Nuance's R&D division


Doctors are burdened by documentation, are AI scribes the answer?

Mobi Health News

Matthew Fradkin, a pediatrician at Swedish Primary Care and Providence St. Joseph, discusses his work implementing an ambient scribe in his workflow at HIMSS20 Digital.

Study: Examining the Clinical Documentation Improvement Landscape

Electronic Health Reporter

When hiring professionals for clinical documentation improvement (CDI) programs, managers seek candidates with a background in both clinical and health information management (HIM) knowledge—challenging a common perception that a clinical background alone is sufficient, according to a recent survey by the American Health Information Management Association (AHIMA). The article Study: Examining the Clinical Documentation Improvement Landscape appeared first on

Google demos its EHR-like clinical documentation tool

Mobi Health News

News of the tool, currently in clinical pilots, comes a week after reports circulated that Google was working with healthcare system Ascension on a controversial project involving patient data

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Optimizing Process and Document Automation in Healthcare

Electronic Health Reporter

The article Optimizing Process and Document Automation in Healthcare appeared first on Editorial Document Automation in Healthcare healthcare automation Nintex patient admissions Physician contract managementThis content is copyrighted strictly for Electronic Health Reporter. By William Sandy, digital marketing, Nintex. The healthcare industry is already well on its way to digital transformation.


Mobile Health Document Sharing (MHDS) Profile

Healthcare Exchange Standards

This profile shows how to build a Document Sharing Exchange using IHE profiled FHIR® standard, rather than the legacy IHE profiles that is dominated by XDS and HL7® v2. This profile will assemble profiles and define a Document Registry.

Microsoft to Integrate Epic EHR and Nuance Automated Documentation with Teams Tool

Healthcare IT Today

Microsoft has announced two deals leveraging its Teams tool which could cast a long shadow over the rapidly evolving telehealth sector. The tech giant signed an agreement with Epic under which the EHR vendor would become the first such organization to use the Teams connector function.

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COVID-19 Immunization Summary Document - use-case analysis

Healthcare Exchange Standards

It is very true that this document does include a Immunizations Section. Lets call this the "COVID-19-Immunization-Summary-Document" (C19ISD) YES, it is a "D" Document. This is why the Document is a Document.

Physicians May Be Documenting Care That They Don’t Provide

Healthcare IT Today

A newly-published study suggests that physicians may not be performing all of the services they document. While the study tracked medical residents rather than physicians who had completed their training, researchers seem to have concluded that their problems with adequate documentation might point to problems affecting all physicians.

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Just because EMRs can document everything doesn’t mean they should


It's always kind of a surprise when you read a patient's chart, and you see an examination of a body part they just don't have. Just the other day, I was reading a consult note on a patient of mine who had been seen by a subspecialist for evaluation of a serious issue, and I […]. Find jobs at Careers by Search thousands of physician, PA, NP, and CRNA jobs now. Learn more. Tech Health IT

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Technology Solutions for Optimizing Clinical Documentation

Healthcare IT Today

Clinical documentation is widely known to be a time-consuming task. Much of that documenting rests on the shoulders of nurses, who use health information technology to help juggle their many roles: […]. Clinical EMR-EHR Health IT Company Healthcare IT Hospital - Health System Clinical Documentation Elsevier Evidence Based Care Fragmented Care Jessica Campbell LogicStream Health Nurse Documentation Tiffany McCauley

Telehealth Documentation

Telebehavioral Health Institute

How to Stay Out of Hot Water: Telehealth Documentation! Easy 3-Part TBHI Online Webinar Series) 6 CE Hours Available Have you updated your telehealth documentation to address recent state and association specific requirements? Reviewing your documents has never been easier. The post Telehealth Documentation appeared first on TBH Institute Blog.

If This Is Human Documentation, Give Me Sweet, Nonjudgmental AI

Healthcare IT Today

AI/Machine Learning Ambulatory Analytics/Big Data Clinical EMR-EHR Health IT Company Healthcare IT Hospital - Health System IT AI-Driven Medical Records Open Notes Patient Medical Records Physician Documentation VIsit Documentation Visit NotesNot long ago, I wrote about what happened when I requested a digital copy of my medical records from my healthcare provider, Kaiser Permanente.

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Community Based Healthcare System Leverages AI-Powered Document Processing to Close Care Gaps

Healthcare IT Today

AI/Machine Learning C-Suite Leadership Health IT Company Healthcare IT Hospital - Health System Healthcare AI Healthcare Document Processing Healthcare NLP Healthcare Transformation Healthcare Triangle Isaac Ellis Monument Health

Creating documents in clinFHIR 


I did a demo of clinFHIR for the Clinicians on FHIR group that will be meeting at the Working Group Meeting next week, and completely forgot to talk about creating/viewing documents in clinFHIR using the scenario builder. This is functionality that has been around for a while, and allows you to create a FHIR document by adding a Composition resource to the scenario, and then linking up the other resource to it. Note the Document tab in the middle pane (next to the Graph).


Providers Increasing Adoption of AI-Fueled Clinical Documentation Technology

Healthcare IT Today

AI/Machine Learning Ambulatory EMR-EHR Health IT Company Healthcare IT HIM Hospital - Health System IT Revenue Cycle Management Black Book Research Clinical Documentation Improvement Computer Assisted Coding Healthcare Workflow Hospital Case Management

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FHIR Documents (and other stuff)


We’d likely think of a clinical note as a Document – a summary at a point in time that should be persisted in the clinical notes, and that leads us to the Composition resource. This text is important as it is used to render the overall document into a human readable form (along with the text from the Patient resource and the Composition itself – see the formal description of this). There’s a lot more to say about documents in FHIR – but hopefully this describes the basics.


Industry Voices—Not all automation is created equally for clinical documentation improvement

Fierce Healthcare

Industry Voices—Not all automation is created equally for clinical documentation improvement. hlandi. Wed, 09/15/2021 - 15:26


Webinar on Document Sharing HIE on FHIR

Healthcare Exchange Standards

Webinar recording is available that covers the Document Sharing Health Information Exchange (HIE) on FHIR.

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Set of documents that are very focused #FHIR

Healthcare Exchange Standards

I outline in the last article that a Document Sharing "document" does not need to be a "Document". I propose that there might be a set of documents that are very focused on specific concepts, or Document sections. The result is about 15 new document types.


The Value of Integrating Clinical Procedure Documentation with Labs

Healthcare IT Today

Pairing that data with clinical procedure documentation is a powerful combination. One of the most valuable integrations you can do in healthcare is integrating lab data.

Mobile Health Document Sharing (MHDS) - First Public Comment

Healthcare Exchange Standards

The Mobile Health Document Sharing (MHDS) Profile is a 100% FHIR Document Sharing infrastructure leveraging many IHE FHIR profiles including MHD. MHDS is published for public comment. This is the first of two Public Comment periods, with the next one this spring.


Study: Provider Experience Affects EHR Documentation Time

hea!thcare innovation - Clinical IT

It’s been widely-referenced that physicians spend large chunks of their days documenting patient encounters using electronic health records (EHRs), and now a new study has pointed to provider experience being a key factor in just how much time

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Medical documentation AI system Sopris Health raises $3.4M

Mobi Health News

The Denver-based startup designed an AI system that lets doctors capture their conversations with patients and transfer those notes to EHRs.

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CMS's 2019 proposal makes broad strides in telehealth, interoperability, documentation

Mobi Health News

The Centers for Medicare and Medicaid Services released its new proposed Physician Fee Schedule and Qualified Payment Program updates for 2019, and the announcement includes some big strides forward in promoting digital health technology, including widened telemedicine coverage, an overhaul of documentation requirements, and a new focus on interoperability

AHIMA Develops Tools To Help Clinical Documentation Integrity Professionals During COVID-19

Electronic Health Reporter

With clinical documentation integrity (CDI) professionals playing a key role in efforts to “flatten the curve” of the COVID-19 pandemic, the American Health Information Management Association (AHIMA) has developed tools designed to ease administrative burdens […]. The article AHIMA Develops Tools To Help Clinical Documentation Integrity Professionals During COVID-19 appeared first on

Clinical Documentation Improvement Top Priority for Hospitals

BHM Healthcare Solutions

Editor’s Note: BHM watches health trends and understands the importance of improving clinical documentation and improving the industry. Hospitals are increasingly implementing clinical documentation improvement technologies, according to a Black Book survey. “The need for proper clinical documentation improvement driving quality outcome scores has never been more essential,” said Doug Brown, managing partner of Black Book.