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Maximizing Your Medical Assistant's Role | AAFP

    https://www.aafp.org/pubs/fpm/issues/2016/0500/p5.html
    In this example, my MA prints an ultrasound request and instructions on scheduling it and gives it to the patient. I finish the note, leaving it open if other referrals or vaccines are needed,...

5 Ways for Medical Assistants to Improve their …

    https://www.gwinnettcollege.edu/5-ways-medical-assistants-improve-documentation-skills/
    Recording essential detail such as vital signs, pain control and a change in condition are a must. Be descriptive and set out what happened and what was …

Pre-Visit Planning - American Medical Association

    https://edhub.ama-assn.org/steps-forward/module/2702514
    A medical assistant (MA) or another team member who can schedule the appointments and tests indicated by the physician can use the visit planner checklist. …

How to Improve Your Medical Assistant …

    https://medhomeinfo.org/medical-assistant-charting-practice/
    One of the most common mistakes made in medical charting is failing to include all relevant information. When documenting a patient’s history, be sure to include …

Team Documentation Improve Efficiency of …

    https://edhub.ama-assn.org/steps-forward/module/2702598
    Example: Cleveland Clinic In the family medicine practice of Kevin Hopkins, MD, at the Cleveland …

Clinical documentation | How to document …

    https://onthewards.org/how-to-document-well/
    Begin by documenting exactly who is present in the meeting, and their roles. For example, family members, medical staff, social workers. Document if a …

Chapter 07: SIMPLE SOAP – NOTE …

    https://psu.pb.unizin.org/ptamedicaldocumentation/chapter/chapter-7/
    Example 4: What’s missing? So now you have seen a few examples of SOAP notes. All very generic and primarily focused for an outpatient clinic. Let’s look over this …

Documentation Matters Toolkit | CMS

    https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation
    Documentation Matters Fact Sheet for Medical Professionals (PDF) (3 pages) Documentation Matters Fact Sheet for Behavioral Health Practitioners …

Nurse Charting 101 | Berxi™

    https://www.berxi.com/resources/articles/nurse-charting-101/
    What Types of Things Should You Document in a Patient’s Chart? The information you put in a patient’s medical record should more or less track the nursing …

15 Not-So-Obvious Documentation

    https://nursemoneytalk.com/blog/charting-tips-for-nurses
    For example, if you’re charting system is electronic many of them have flowsheets. Your electronic charting system might call it something different. Regardless the main …



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