Clinical Documentation

If you work in healthcare, you know how scary it can be to share important news about a patient. What […]

What Is a Source-Oriented Medical Record? A Source-Oriented Medical Record (SOMR) is a way to organize a patient’s medical information.

If you work in healthcare or are studying to be a doctor, nurse, or medical assistant, you know one thing

If you have been a nurse for even one shift, you know this truth: charting takes forever. You finish giving

As an occupational therapist, you help people do the things they want and need to do every day. But after

As a clinician with years of experience, I can tell you that the most powerful tool I own is not

Let’s be honest for a moment. When was the last time you finished a patient encounter and felt a deep

If you are a new nurse or a nursing student, you have probably heard the words “charting” or “documentation” more

As a nurse, your hands do a thousand things in a shift. You start IVs, you hold a patient’s hand,

If you work in mental health, you know that note-taking is part of the job. You see clients, you help them, and