Medical Documentation Article

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SOAP Notes - StatPearls - NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK482263/

Mastering the Basics of Medical Documentation - The …

https://www.npjournal.org/article/S1555-4155(07)00078-5/fulltext

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history, including past and present illnesses, …

Importance of Documentation | Office of Inspector …

https://oig.hhs.gov/newsroom/oig-podcasts/importance-documentation/

Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate …

Electronic medical documentation: Attitudes and trends.

https://journals.lww.com/jaapa/Fulltext/2020/02000/Electronic_medical_documentation__Attitudes_and.9.aspx

An electronic documentation system improves the quality of admission notes: a randomized trial. J Am Med Inform Assoc. 2017;24 (1):123–129. 3. Boonstra A, Broekhuis …

Strategies for improving physician documentation in the …

https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-018-0188-z

Chart accuracy is both a measure and a means of ensuring the quality of the care that patients receive [].Accurate patient chart information can facilitate and further …

Improving the quality of medical record documentation

https://pubmed.ncbi.nlm.nih.gov/10119893/

Abstract. Accurate and complete medical record documentation is essential in any healthcare setting. In addition to communicating vital patient care information, the …

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 …

Clinical documentation | How to document …

https://onthewards.org/how-to-document-well/

In the case of any legal proceedings, documentation is heavily scrutinised to help support an argument either way. Documenting sensitive discussions …

Medical documentation practice and associated factors …

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-07809-6

Medical documentation is an detail information or evidence for patients and a significant part of patient care due to medical reporting [].Documentation is a way of …

Article - Standard Documentation Requirements for All …

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=55426

Article Text. Many errors reported in Medicare audits are due to claims submitted with incomplete or missing requisite documentation. Consequently, the …

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