Clinical Documentation
EHR Implementation
An EHR (Electronic Health Record) is a digital version of a patient’s paper chart. It holds medical history, test results,...
Clinical resources
Blog
Clinical documentation guides, AI scribe resources, and medical documentation examples.
Clinical Documentation
EHR Evaluation Checklist
If you work in a doctor’s office, a clinic, or a hospital, you already know how important health records are....
CE
Clinical Evidence
Clinical Documentation
Clinical Evidence
Clinical evidence is the foundation of modern healthcare. Every diagnosis, treatment plan, medication, therapy intervention, and patient care decision should...
Generate BIRP
Clinical Documentation
The Best AI BIRP Note Generator 2026
If you are a therapist, psychiatrist, doctor, or nurse, you know how much time writing notes takes. You likely spend hours every week typing what happened in each session. This...
Generate ABA
Clinical Documentation
Best AI ABA Session Notes Generator 2026
As a professional in Applied Behavior Analysis (ABA), you know that writing session notes is an important part of the job. But let's be real, it's often the part you dread the m...
Generate DAP
Clinical Documentation
Best AI DAP Note Generator 2026
Clinical documentation is one of the biggest challenges in modern healthcare. Therapists, psychiatrists, psychologists, physicians, nurses, counselors, social workers, and many...
Generate AI Progress
Clinical Documentation
The Best AI Progress Note Generator 2026
Healthcare professionals spend a huge amount of time writing notes. Therapists finish sessions and still need to complete progress notes. Doctors see patients all day and then s...
MS
Mental Status Exam (MSE) Cheat Sheet: Checklist & Examples
Clinical Documentation
Mental Status Exam (MSE) Cheat Sheet: Checklist & Examples
When a patient comes to see us, we check their blood pressure and listen to their heart. But we also need to check their mind. The Mental Status Exam (MSE) is our tool for that....
F41.1
Diagnosis code guide
Clinical Documentation
2026 ICD-10 Diagnosis Code F41.1: Generalized Anxiety Disorder (GAD)
We see patients every day who feel worried all the time. They cannot seem to turn off their anxious thoughts. This is different from normal stress before a test or a big meeting...
Psychotherapy No
vsProgress Notes
Clinical Documentation
Psychotherapy Notes vs. Progress Notes
If you have ever felt confused about the difference between psychotherapy notes and progress notes, you are not alone. Many therapists, counselors, social workers, and psychiatr...
H&P
vsSOAP Notes
Clinical Documentation
H&P vs SOAP Notes
Let’s be honest. Nobody went to medical school because they loved writing notes. You went to school to help people feel better. But here we are, spending hours in front of a com...
BIRP
vsSOAP Notes
Clinical Documentation
BIRP vs SOAP Notes
Let’s be honest. You did not become a nurse, therapist, doctor, or counselor because you love paperwork. You became a healer because you want to help people. But good notes are...
SOAP Notes
vsDAP Notes
Clinical Documentation
SOAP Notes vs DAP Notes
As a healthcare professional, you write notes every day. These notes tell the story of your patient's care. Good notes help other doctors understand what happened. Bad notes can...
Z91.81
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code Z91.81: History of Falls
Falls are a big problem in healthcare. Many patients, especially older adults, fall at home or in hospitals. When a patient has a history of falls, it changes how you take care...
J45.909
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code J45.909: Reactive Airway Disease
You have seen the term "Reactive Airway Disease" or RAD on patient charts many times. It is a common phrase used when a patient has wheezing, coughing, or trouble breathing. But...
M54.12
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code M54.12: Cervical Radiculopathy
Why This Code Matters in Your Daily Practice As a healthcare professional, you know that coding is not just about billing. It is about telling a clear story of your patient’s he...
I50.2
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code I50.2: Heart Failure with Reduced Ejection Fraction (HFrEF)
Why Getting This Code Right Matters More Than You Think As healthcare professionals, we know that heart failure is not a single disease. It is a complex syndrome with different...
M54.16
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code M54.16: Lumbar Radiculopathy
You see patients with leg pain every day. They tell you about a burning feeling that starts in their low back and shoots down to their foot. You know this is lumbar radiculopath...
R06.02
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code R06.02: Shortness of Breath
You see shortness of breath every day. It is one of the most common reasons patients come to the ER, the clinic, or the hospital floor. But when you sit down to bill for that vi...
E87.6
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code E87.6: Hypokalemia
What Is Hypokalemia? Hypokalemia is a medical term that means your patient has too little potassium in their blood. Potassium is a mineral that helps muscles work, nerves send s...
K52.9
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code K52.9: Chronic Diarrhea
For medical coders, gastroenterologists, and primary care providers, few ICD-10 codes appear as frequently, or cause as much confusion, as K52.9. Officially labeled "Noninfectiv...
Clinical Documentation
Advantages and Disadvantages of Electronic Health Records
If you work in a clinic, a hospital, or even a home health agency, you spend more time with your computer than you do with some of your family members. That glowing screen holds...
HO
History of Electronic Health Records: A Simple Timeline for Healthcare Professionals (Then, Now, Future)
Clinical Documentation
History of Electronic Health Records: A Simple Timeline for Healthcare Professionals (Then, Now, Future)
If you work in healthcare, whether you are a doctor, a nurse, a medical assistant, or someone at the front desk, you spend a huge part of your day with an Electronic Health Reco...
G62.9
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code G62.9: Peripheral Neuropathy
As healthcare professionals healthcare, we spend years learning about nerves, muscles, and how the body talks to itself. We learn to spot the signs of trouble. But when it comes...
R74.01
Diagnosis code guide
Medical Codes
2026 ICD-10 Diagnosis Code R74.01: Transaminitis
Have you ever looked at a lab report and seen high liver enzyme numbers? Your first thought might be "something is wrong with this patient's liver." But what exactly is it? This...
Clinical Documentation
Source-Oriented Medical Record (SOMR)
What Is a Source-Oriented Medical Record? A Source-Oriented Medical Record (SOMR) is a way to organize a patient’s medical information. In this system, each healthcare departmen...
ST
SBAR Tool (Situation, Background, Assessment, Recommendation) (with Examples)
Clinical Documentation
SBAR Tool (Situation, Background, Assessment, Recommendation) (with Examples)
If you work in healthcare, you know how scary it can be to share important news about a patient. What if you forget something? What if the doctor does not listen? What if a mist...
Clinical Documentation
Problem-Oriented Medical Record (POMR)
If you work in healthcare or are studying to be a doctor, nurse, or medical assistant, you know one thing for sure: keeping good records is very important. But not all records a...
Clinical Documentation
Charting by Exception
If you have been a nurse for even one shift, you know this truth: charting takes forever. You finish giving medications, answering call lights, and comforting a worried family....
Clinical Documentation
Occupational Therapy Documentation (OT Notes): with Examples and Cheat Sheet
As an occupational therapist, you help people do the things they want and need to do every day. But after you finish helping a child tie their shoes or teaching an older adult h...
HT
History Taking
Clinical Documentation
History Taking
As a clinician with years of experience, I can tell you that the most powerful tool I own is not a fancy machine or a sharp scalpel. It is a simple, ancient skill: asking questi...
Clinical Documentation
Narrative Notes
As a nurse, your hands do a thousand things in a shift. You start IVs, you hold a patient’s hand, you give medications, and you answer call lights. But one of the most important...
Clinical Documentation
Clinical Documentation Improvement (CDI)
Let’s be honest for a moment. When was the last time you finished a patient encounter and felt a deep sense of satisfaction from writing the note? For most of us, the note is th...
Clinical Documentation
DAR Notes
If you are a new nurse or a nursing student, you have probably heard the words “charting” or “documentation” more times than you can count. Your instructors say it. Your precept...
SN
SIRP Notes
Clinical Documentation
SIRP Notes
If you work in mental health, you know that note-taking is part of the job. You see clients, you help them, and then you have to write it all down. This can feel like a burden....
Clinical Documentation
GIRP Notes (with Examples)
Writing notes during or after a therapy session can feel like a lot of work. We spend our days connecting with people, listening to their deepest struggles, and helping them fin...
Clinical Documentation
How to Write PIRP Notes (with Examples)
Clinical documentation is often the most dreaded part of our work. You finish a meaningful session, and then comes the blank screen, the mental block, and the pressure to produc...
Clinical Documentation
PIE Notes (with Examples)
Let’s be honest for a second. How do you feel when you have to sit down and write your progress notes at the end of the day? For many of us, it can feel like a chore. We might r...
PN
Progress Notes
Clinical Documentation
Progress Notes
If you work in healthcare, you know that paperwork is a big part of the job. One of the most important pieces of paperwork we write every day is the progress note. A progress no...
Clinical Documentation
BIRP Notes (with Examples)
As a clinician, I know that writing notes is probably not your favorite part of the job. It can feel like a tedious task that takes you away from your clients. But good notes ar...
Clinical Documentation
DAP Notes
As clinicians, we chose this path to help people. We want to listen to our clients, help them work through their problems, and celebrate their progress. But for many of us, ther...
Clinical Documentation
Doctor’s Note (with Template & Examples)
A doctor’s note is a short medical document written by a doctor or another licensed healthcare professional. It explains a patient’s health condition in simple terms and may rec...
PN
Psychiatric Nursing Notes (with Examples)
Clinical Documentation
Psychiatric Nursing Notes (with Examples)
Writing nursing notes is a big part of every psychiatric nurse's day. Some nurses enjoy the documentation process. Others find it tedious and put it off until the end of their s...
Clinical Documentation
General Anxiety Disorder - Seven Item (GAD-7)
If you work with patients, you deal with anxiety every single day. It hides behind headaches. It fuels high blood pressure. It ruins sleep. And often, patients do not know how t...
Clinical Documentation
How to Write a Good Discharge Summary Note (with Examples)
As medical professionals, we spend a lot of time focusing on the beginning of a patient's journey with us: the admission note, the history and physical, the initial orders. But...
Clinical Documentation
How to Write ABA Notes (with Examples)
If you work in Applied Behavior Analysis (ABA), you have probably heard the saying: “If it isn’t written down, it didn’t happen.” This is the golden rule of our field. We spend...
MS
Mental Status Examination (MSE)
Clinical Documentation
Mental Status Examination (MSE)
If you work in healthcare, whether you're a psychiatrist, nurse, a medical student, a resident, or a social worker, you've probably heard the term "Mental Status Exam" or "MSE."...
Clinical Documentation
SOCRATES (Pain Assessment)
Have you ever had a patient try to describe their pain, and it just comes out as a confusing jumble of words? They might say, "It just hurts, doc. It's a bad one." As healthcare...
Clinical Documentation
Patient Health Questionnaire (PHQ-9)
As clinicians, we are always looking for tools that help us understand our patients better. We need ways to measure what they are feeling, especially when those feelings are har...
Clinical Documentation
The Clinician's Guide to Building Effective Treatment Plans
Whether you're a therapist, a social worker, a nurse, or a doctor, you write treatment plans. It might feel like just another piece of paperwork, a checkbox to please the insura...
TS
Trauma SOAP Notes (with Examples)
Clinical Documentation
Trauma SOAP Notes (with Examples)
Trauma is one of the most common reasons people seek therapy, counseling, and mental health support. Many clients experience trauma from childhood, relationships, accidents, vio...
Clinical Documentation
Social History (medicine) SocHx
As a medical professional, I understand that we often rush through the "SocHx" portion of our H&P. We might jot down "smokes, drinks, lives with wife" and move on. But in modern...
Clinical Documentation
SAMPLE History
Why SAMPLE History Matters If you work in healthcare, you know that time is often not on your side. Whether you are in an emergency room, an ambulance, or a clinic, you need to...
Clinical Documentation
OPQRST
Why Asking the Right Questions Matters As medical professionals, we know that a patient's story holds the answers. Often, the key to diagnosis lies not in the first test we orde...
AS
Best AI Scribe for Psychiatry (2026)
Clinical Documentation
Best AI Scribe for Psychiatry (2026)
Being a psychiatrist is tough. You listen, you care, you solve deep problems. But then comes the paperwork. Notes, treatment plans, progress summaries. It takes hours. Time you...
Clinical Documentation
Vital Signs (with Examples & Template)
Think of vital signs as the body's most basic news report. Before a patient says a word about their headache, before we see an X-ray, or before we get blood test results, the vi...
Clinical Documentation
Anxiety SOAP Notes (with Example)
As healthcare professionals, in our work, we see many patients struggling with anxiety. It is a common condition. It can be hard to treat. Good notes are our best tool. They hel...
Clinical Documentation
SOAPIE Charting (with Examples)
If you work in healthcare, you know that good communication is everything. What we write in a patient's chart is a crucial part of that communication. It keeps the whole team on...
SN
SOAP Notes (with Examples & Template)
Clinical Documentation
SOAP Notes (with Examples & Template)
As healthcare professionals, our primary mission is clear: to understand our patients and guide them toward better health. Yet, in the whirlwind of a busy shift, be it in a bust...
Clinical Documentation
OLD CARTS
When a patient comes to you, they bring more than just a symptom. They bring a story. This story holds the key to understanding what is wrong. The most advanced scans and lab te...
Press Release
Skriber Joins Forces with Athenahealth, Redefining the Physician-Workflow Standard
As healthcare continues to change, the smooth flow of information is not just a convenience; it’s an important component of patient safety, provider satisfaction, and operationa...
Clinical Documentation
Past Medical History (PMH)
Today, we are going to talk about one of the most important parts of our job. It is not a new machine or a complex test. It is something we do every day: taking a patient's past...
TA
Top 10 AI SOAP Note Tools in 2026 (Reviewed by Real Clinicians)
Clinical Documentation
Top 10 AI SOAP Note Tools in 2026 (Reviewed by Real Clinicians)
Tired of spending hours each night writing notes instead of being with family? You’re not alone. Doctors, therapists, and medical practitioners across every specialty are drowni...
Clinical Documentation
Depression SOAP Note Example
Let's talk about depression. It's not just feeling sad for a day. It is a real medical condition. It affects how you feel, think, and act. It can make everyday tasks feel very h...
Press Release
Skriber & eClinicalWorks Integration: A New Era of Automated Charting
In healthcare documentation, the most valuable currency isn't money; it's time. The new integration between Skriber and eClinicalWorks directly deposits hours back into the work...
Clinical Documentation
Biopsychosocial Assessment (with Examples)
Introduction: Seeing the Whole Person When a patient walks into your office, what do you see? You see their symptoms. You hear their complaints. But is that the whole story? For...
CC
Chief Complaint (CC)
Clinical Documentation
Chief Complaint (CC)
Imagine you walk into a doctor’s office. You are feeling sick. You have many things to say. Your head hurts. Your stomach feels strange. You have been tired for weeks. Where do...
Clinical Documentation
History of Present Illness (HPI)
The History of Present Illness (HPI) is the heart and soul of any medical visit. It’s a detailed, chronological narrative of the problem that brought the patient in. It’s not ju...
Clinical Documentation
History and Physical (H&P): Your Most Powerful Medical Tool
What is an H&P, and Why is it So Important? Imagine you are a detective. A crime has happened, and you are called to the scene. You wouldn't just guess who did it. You would loo...
Clinical Documentation
Clinical Words to Use in Progress Notes
Progress notes are a part of everyday clinical work. They tell the ongoing story of a patient’s care and progress. A strong note is clear, accurate, and easy to understand. It h...
AS
The 10 BEST AI Scribes (2026)
Clinical Documentation
The 10 BEST AI Scribes (2026)
AI medical scribes have moved from early experimentation to everyday clinical tools. In 2026, clinicians are no longer asking whether to use an AI scribe, but which one truly fi...
Clinical Documentation
How to write Psychiatry Notes (with Examples)
Psychiatry notes are one of the most important tools in mental health care. They help psychiatrists record patient symptoms, clinical thinking, treatment decisions, and progress...
Clinical Documentation
SOAP Notes Plan (with Examples)
SOAP notes are one of the most widely used clinical documentation formats in healthcare. They help professionals record patient information in a clear, logical, and structured w...
Clinical Documentation
SOAP Notes in Physiotherapy (with Examples)
SOAP notes are one of the most important documentation tools used in physiotherapy practice. They provide a clear and structured way to record patient information, clinical find...
AS
Acupuncture SOAP Notes (with Examples)
Clinical Documentation
Acupuncture SOAP Notes (with Examples)
SOAP notes are a simple and clear way to document patient care. In acupuncture practice, SOAP notes help track symptoms, treatment points, patient response, and progress over ti...
Clinical Documentation
SOAP Notes for Asthma (with Examples)
Asthma is a long-term breathing condition that affects the airways of the lungs. People with asthma have sensitive airways that can swell, tighten, and produce extra mucus. This...
Clinical Documentation
Orthopedic SOAP Notes (with Examples)
Orthopedic care focuses on bones, joints, muscles, ligaments, and movement. Every orthopedic visit depends on clear and accurate documentation. One of the most trusted and widel...
Clinical Documentation
The Best HIPAA Compliant Dictation Software
Healthcare work today moves very fast. Doctors, therapists, nurses, and other clinicians must finish many notes every day while also giving full attention to their patients. Bec...
RO
Review of Systems (ROS) (with Checklist Template)
Clinical Documentation
Review of Systems (ROS) (with Checklist Template)
The review of systems , often called ROS , is a very important part of medical and clinical documentation. It helps healthcare providers understand how a patient feels across di...
Clinical Documentation
HIPAA-Compliant Transcription Software
If you work in healthcare, you already know the problem: you have patients to care for, but you also have charts to finish. Notes take time. Typing is slow. Copy-paste templates...
Clinical Documentation
Musculoskeletal SOAP Notes (with Examples)
Musculoskeletal problems are extremely common in everyday clinical practice. Many patients visit clinics for pain in their muscles, joints, ligaments, or bones. Because these co...
Clinical Documentation
Cardiac SOAP Notes (with Examples)
Cardiac problems are very common in clinics, hospitals, and emergency settings. Conditions like chest pain, palpitations, shortness of breath, and high blood pressure often requ...
SN
SOAP Notes for Hypertension (with Examples)
Clinical Documentation
SOAP Notes for Hypertension (with Examples)
Hypertension, commonly known as high blood pressure, is one of the most widespread health problems worldwide. What makes it especially dangerous is that it often shows no obviou...
Clinical Documentation
SOAP Notes Cheat Sheet
Health and mental health professionals write SOAP notes as part of their daily work. These notes help document a client’s condition, track changes over time, and guide treatment...
Clinical Documentation
SOAP Notes Subjective: (with Examples)
Documentation is one of the most important responsibilities in healthcare, and the quality of those notes can greatly affect treatment decisions, patient outcomes, and clinical...
Clinical Documentation
The Best HIPAA Compliant Note-Taking App
In healthcare, note-taking is a major part of daily work. Clinicians write notes to understand a patient’s condition, track progress, communicate with other providers, and prote...
PA
Priming the Ambient AI Medical Scribe with Skriber:
Press Release
Priming the Ambient AI Medical Scribe with Skriber:
Insights from Dr. Connor Yost’s Interview with Healthcare IT Today In a recent interview with Healthcare IT Today , Chief Medical Officer Dr. Connor Yost shared the full story b...
Generate SOAP
Clinical Documentation
SOAP Note Generator
Writing SOAP notes is a daily part of every clinician’s job, but it can also be one of the most time-consuming tasks. Doctors, therapists, nurses, and other healthcare professio...
Clinical Documentation
Using ChatGPT for SOAP Notes: Benefits, Limitations, and HIPAA Concerns
SOAP notes are a daily part of clinical life. They help you record symptoms, document assessments, and plan treatment in a clear and structured way. Many clinicians today are ex...
AI-Generated Cli
vsHuman Notes
Clinical Documentation
AI-Generated Clinical Notes vs Human Notes (Manual Note-Taking)
Clinical documentation is one of the most important tasks in healthcare. Every patient visit must be recorded clearly, correctly, and on time. Doctors, nurses, therapists, and o...
PS
Pediatric SOAP Notes (with Examples & Template)
Clinical Documentation
Pediatric SOAP Notes (with Examples & Template)
As a pediatrician, you see children of all ages, from newborns to teenagers, and every visit can be very different. One thing, however, should always stay the same: clear and st...
Press Release
Skriber Raises $1.3M to Help Clinicians Take Back Their Time
We’re excited to share a major milestone for Skriber: we’ve officially closed our oversubscribed pre-seed funding round, raising $1.3 million to continue our mission of ending d...
Clinical Documentation
How to Write Assessment in SOAP Note (with Examples)
The Assessment section is one of the most important parts of a SOAP note because it shows how you, as the clinician, make sense of all the information from the visit. It is wher...
Clinical Documentation
How to Write Objective in SOAP Notes (with Examples)
The Objective section in a SOAP note is one of the most important parts of clinical documentation. It contains the facts you can see, hear, measure, or test, and it helps show t...