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Medical Records

3 Pathology Synoptic Reporting Examples

October 21, 2014 by Tim Edlund

Structured practices for pathology reporting, and particularly use of template (synoptic) formats, have been demonstrated to improve reporting quality. Pathologists are fortunate in that a comprehensive library of peer reviewed templates is provided by the College of American Pathologists in the form of the CAP Cancer Checklists.[read more]

Clinical Documentation Improvement: Why Care About Synoptic Reporting?

October 19, 2014 by Tim Edlund

clinical documentation

Synoptic reports provide a more complete view of a patient’s condition than is generally achieved with longer narrative formats. They are computer-based worksheets that medical professionals use to enter and obtain information in a manner that is quicker and more accurate than free-text reports.[read more]

iPad EHR Drchrono Gears Up for HealthKit

October 16, 2014 by David E Williams

HealthKit and Drchrono

Drchrono bills itself as the “original mobile EHR built for the iPad.” With that in mind, I decided to ask the company’s co-founder and COO, Daniel Kivatinos for his thoughts on Apple’s entry into the healthcare space with its new Health app and HealthKit development tool. Here are my questions and his replies.[read more]

Apple HealthKit: Epic Integration at Ochsner Health System

October 16, 2014 by David Harlow

HealthKit

The first health system to announce that it had integrated HealthKit into its Epic EHR is Ochsner Health System in Louisiana. It is a 12-hospital, 40-clinic operation with over 900 physicians. I spoke recently with Dr. Richard Milani, Ochsner's Chief Clinical Transformation Officer. Here's what we talked about.[read more]

Ebola or Epic: Which Do US Hospitals Fear More?

October 9, 2014 by David E Williams

emergency room / shutterstock

I don’t laugh easily, but I did chuckle when I heard that a Texas hospital was blaming its electronic medical record for the hospital’s mishandling of the first Ebola case in the US. iHealthBeat does a very nice job of summarizing the situation and speculating on what really occurred.[read more]

Why I Won't Refill Your Prescription

October 7, 2014 by Michael Kirsch

refills / shutterstock

Patients contact us nearly every day for prescription refills. Of course, we beg them to do so when they are in the office, but life doesn’t work this way and I understand this. Here are some instances when I will not refill the requested medicine.[read more]

New Technologies Are Defining Health Information Management

October 7, 2014 by Seth Kneller

source: TripleTree Analysis

In late August on these pages, we offered some views on provider adoption of EMR software. Several companies with roots in the HIM sector have emerged in recent years to address the gaps and limitations associated with most EHR deployments.[read more]

Benefits of Outsourcing Your Medical Claims Processing

October 6, 2014 by Alleli Aspili

Outsource your medical claims?

There was a time in the past when the tedious and complicated task of medical claims processing was a hands-on responsibility for physicians and doctors. Now, healthcare organizations get a lot more when they outsource their medical claims processing tasks to a third party.[read more]

Follow These DOs and DON'Ts When Comparing EHR Software

October 4, 2014 by Shahid Shah

Dos and Don'ts / shutterstock

Although I’ve written and spoken extensively in the past about how to make sure you pick the right digital health and EHR software, I wanted to put together a new “common sense” type of Do’s and Don’ts list for picking new EHR software. To help me out, I reached out to J.P. Medved at Capterra because of their unique expertise in this area.[read more]

Helping Patients Protect Their Own Personal Health Information

October 1, 2014 by Anne Weiler

I was leaving a meeting at a large hospital when I saw a patient record sitting on top of the payment machine in the parking garage. I took the paper records back into the hospital. But it got me thinking about information protection and privacy, and in particular about the many people who still think that a paper print out is more secure than the cloud.[read more]

CAP Template Providing Too Much Information?

September 30, 2014 by Tim Edlund

Synoptic pathology reports can become quite lengthy, and it is easy for the vital components of the report to get lost. How can you structure a pathology report in such a way that it can be beneficial for every person who is a part of the patient's care team? Efficiently summarizing the key points of the report may be the answer.[read more]

Adrenal Pathology Reporting: How to Prevent Errors with Pathology Reporting Software

September 29, 2014 by Tim Edlund

pathology reporting software

Synoptic reporting has become known for its ease of use, as well as for its ability to assist Pathologists and other practitioners in eliminating errors. The question is, how is it possible to avoid errors when the templates are being provided by CAP?[read more]