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Importance of Preparing/Maintaining Legible Medical …
- https://www.hhs.gov/guidance/document/importance-preparingmaintaining-legible-medical-records
- This MLN Matters® Article Special Edition (SE) is intended for physicians and other providers who document treatment for Medicare beneficiaries and/or submit claims for Medicare Fee-For-Service (FFS) reimbursement. Download the Guidance …
Integrity of the Healthcare Record: Best Practices for …
- https://library.ahima.org/doc?oid=300257
- Innovations are needed to improve documentation tools and techniques; a back-to-the-basics focus on the importance of data accuracy and quality must take priority before …
Improving the quality of medical record documentation
- https://pubmed.ncbi.nlm.nih.gov/10119893/
- In addition to communicating vital patient care information, the medical record provides documentation of appropriate evaluation, treatment, and services. It also is used to …
Legibility, accuracy, specificity vital in records
- https://www.medicaleconomics.com/view/legibility-accuracy-specificity-vital-records
- In addition to making sure your records are legible, here are some points to remember: • Be accurate. Accuracy is especially important with specific medications, …
Integrity of the Healthcare Record: Best Practices for …
- https://flbog.sip.ufl.edu/risk-rx-article/integrity-of-the-healthcare-record-best-practices-for-ehr-documentation/
- Organizations must develop policies designed to address inappropriate use of these tools to minimize non‐compliance. Common documentation risks that can result from cloning features include: Vital signs that never …
Electronic medical records and quality improvement
- https://pubmed.ncbi.nlm.nih.gov/25771280/
- Widespread adoption of electronic medical records (EMRs) in the United States is transforming the practice of medicine from a paper-based cottage industry into an …
Help with making documents more legible?
- https://siarchives.si.edu/what-we-do/forums/collections-care-guidelines-resources/help-making-documents-more-legible
- If you’re working with papers that are faded, the fading of documents is often irreversible, but it may be possible to enhance legibility through two means: virtually, …
Reducing Medical Errors with Improved Communication, …
- https://ehrintelligence.com/features/reducing-medical-errors-with-improved-communication-ehr-use
- First, medical errors must be more visible. Second, remedies must be available to safeguard patients from medical errors. Third, best practices must be shared to make medical errors less frequent.
Electronic Health Record (EHR) Best Practices for …
- https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/policy-statements/information-papers/electronic-health-record-ehr-best-practices-for-efficiency-and-throughput.pdf
- use of a scribe for specific portions of the chart (eg, medical decision making) that require longer passages or may be used alone. In many cases, speech-recognition …
How to keep good clinical records | European …
- https://breathe.ersjournals.com/content/12/4/369
- They should include: 1) All relevant clinical findings. 2) A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. …
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