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Improving clinical documentation: …
- https://bmjopenquality.bmj.com/content/10/1/e000918
- Clinical documentation is the process of generating a structured record of a patient’s medical care. …
Issues in nursing documentation and record-keeping …
- https://pubmed.ncbi.nlm.nih.gov/22241496/
- This article will provide an overview of the literature on record-keeping practice and examine what makes good quality record keeping and the factors that prevent nurses …
Documentation Tips for Reducing Malpractice Risk | AAFP
- https://www.aafp.org/pubs/fpm/issues/2000/0300/p29.html
- Physicians may reduce their risk for such allegations by adhering and updating to appropriate standards of care, open-mindedly approaching evaluations, fostering and …
Quality of nursing documentation: Paper-based health …
- https://pubmed.ncbi.nlm.nih.gov/28981172/
- The study affirmed the poor quality of nursing documentation and lack of nurses' knowledge and skills in the nursing process and its application in both paper-based and …
Complying With Medical Record Documentation …
- https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet
- Complying With Medical Record Documentation Requirements Fact Sheet Learn about proper medical record documentation requirments; how to provide …
5 Best Practices for Medical Documentation - Clinical …
- https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/
- The following are 5 tips on documentation best practices. 1. Document Your Examination Failure to document a physical examination is the most common mistake I …
Clinical documentation | How to document …
- https://onthewards.org/how-to-document-well/
- Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into …
Medical Documentation - an overview | ScienceDirect …
- https://www.sciencedirect.com/topics/nursing-and-health-professions/medical-documentation
- A Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment (Iacopino et al., 2009) has been developed to provide health professionals with essential …
(PDF) Medical Documentation Practice of …
- https://www.researchgate.net/publication/339702613_Medical_Documentation_Practice_of_Health_Professionals_and_Attitude_towards_it_at_University_of_Gondar_Hospital_Gondar_North_West_Ethiopia
- p>Medical documentation is believed as pertinent facts of medicalcare plan. It is a warehouse for patient’s information and interaction with theircaregivers in …
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