Electronic Medical Documentation Standards

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Summary of the HIPAA Security Rule | HHS.gov

https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html

The Security Rule calls this information “electronic protected health information” (e-PHI). 3 The Security Rule does not apply to PHI transmitted orally or in writing. General Rules The Security Rule requires covered entities to maintain reasonable and appropriate …

Electronic Health Records | CMS

https://www.cms.gov/Medicare/E-Health/EHealthRecords

An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of …

Electronic Medical Records Standards – Office of …

https://ooc.usc.edu/compliance-programs/healthcare-compliance/emr-standards/

Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Improving clinical documentation: …

https://bmjopenquality.bmj.com/content/10/1/e000918

The EHR is operationally defined by the US National Institute of Standards and Technology as ‘a …

Complying With Medical Record Documentation …

https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet

Download the Guidance Document. Final. Issued by: Centers for Medicare & Medicaid Services (CMS) Issue Date: April 01, 2017. DISCLAIMER: The contents of this …

Standards for the Content of the Electronic …

https://library.ahima.org/doc?oid=57621

A descriptive, cross-sectional study was performed to measure the awareness, use, and validity of the minimum content recommended in the American Society for Testing …

Standards for Joint Commission Accreditation and …

https://www.jointcommission.org/standards/

The standards review various aspects of your care delivery process, ensuring a comprehensive review of the patient care experience. The accreditation and certification …

Nurse documentation and the electronic …

https://www.myamericannurse.com/documentation-electronic-health-record/

Electronic health records (EHRs) support that documentation with data that help you enhance patient safety, evaluate care quality, maximize efficiency, and …

Electronic Health Records Provider - Centers for …

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf

EHRs allow medical professionals a seamless approach for coordinating and managing their patient records. They can help reduce paperwork, eliminate duplicate tests, and …

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