Clinical documentation is more than just paperwork—it’s the backbone of quality behavioral health care. From SOAP to DAP formats, clear and compliant notes ensure continuity of care, legal protection, ...

Clinical notes have always been a standard for creating narratives that get claims paid because they support the necessity for the services rendered. "If it isn't written, it didn't happen" still ...

In this study, the authors demonstrate widespread adoption and satisfaction with the novel APSO (Assessment, Plan, Subjective, Objective) format for progress notes at a large, integrated health ...

NEW YORK CITY -- Clinical notes for patients with substance use disorder (SUD) contained stigmatizing language -- such as "junkie," "dirty user," and "this drunk" -- on a regular basis, according to a ...

The first fully automatic clinical documentation application powered by OpenAI's GPT-4 is scheduled to be widely released later this year, Nuance and Microsoft announced. This latest artificial ...