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Clinical documentation | How to document medical …
- https://onthewards.org/how-to-document-well/
- 2. It’s a legal document. A medical record is a legal document. So, understand that what you write is memorialised permanently. In the case of any legal proceedings, documentation is heavily scrutinised to help support an argument either …
- https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
- Commonly Accepted Standards for Medical Record Documentation 1. Each page in the record contains the patient’s name or ID number. 2. Personal biographical data include …
ANA’s Principles for Nursing Documentation
- https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf
- Patient clinical reports, providers’ documentation, administrators’ records, and other documents related to patients and organizations providing and supporting patient careare …
Complying With Medical Record Documentation …
- https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet
- Final. Issued by: Centers for Medicare & Medicaid Services (CMS) Issue Date: April 01, 2017 DISCLAIMER: The contents of this database lack the force and effect …
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