Approfondimenti, novità e risorse per i professionisti sanitari
The best-known EMR and EHR systems grouped by who they are built for, with questions to ask before you pick one and how an AI scribe fits in.
A fill-in nursing care plan template, how to write PES nursing diagnoses and measurable goals, and three worked care plan examples you can adapt.
Six worked clinical note examples for everyday outpatient encounters, from a new patient visit to a phone call, plus the mistakes that weaken notes.
A fill-in SBAR template and five worked SBAR examples, from an after-hours clinic call to a shift handoff, plus tips for making each part count.
A complete normal physical exam template by body system, a focused exam example, a head-to-toe assessment checklist, and rules for using templates honestly.
A copy-ready SOAP note template, three worked SOAP note examples from primary care and therapy, and the habits that make each section short and useful.
A practical guide to writing a mental health treatment plan: what goes in it, how to write measurable objectives, a full worked example, and how to keep it current.
A practical guide to the mental status exam: each component, what to write, a full example note, and where an ambient AI scribe helps and where it can't.
A biopsychosocial assessment is the longest note most behavioral-health clinicians write. Here's what it covers, how to keep it usable, and where an ambient AI scribe can take some of the weight.
The history of present illness is the part of the note your colleagues read first. Here's the format, the eight classic elements, an example, and how an ambient AI scribe drafts it from the visit.
The review of systems still matters, just not the way it used to. Here's what the 14 systems are, what changed with office E/M coding, and how to keep an ROS useful instead of cloned.
“Ambient clinical documentation” is the enterprise name for AI that drafts notes from the visit. Here’s what the term means in practice — and what to ask before you buy.
