Medical Documentation Charting

Ten EHR Strategies for Efficient Documentation | AAFP

https://www.aafp.org/pubs/fpm/issues/2020/0700/p5.html

STRATEGIES FOR HPI DOCUMENTATION 6. Use patient questionnaires to gather data. For a review of systems (ROS) or other common scenarios (PHQ-9, sleep apnea, adult …

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 …

Guidelines for Medical Record Documentation

https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf

Commonly Accepted Standards for Medical Record Documentation 1. Each page in the record contains the patient’s name or ID number. 2. Personal biographical data include …

Nurse Charting 101 | Berxi™

https://www.berxi.com/resources/articles/nurse-charting-101/

Narrative Notes. Narrative nurses notes are like a running log of everything …

Documentation Matters Toolkit | CMS

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

Exam Documentation: Charting Within the Guidelines

https://www.aafp.org/pubs/fpm/issues/2010/0500/p24.html

Detailed – should include performance and documentation of at least two bulleted elements from each of six organ systems or body areas OR performance and documentation of at …

5 Best Practices for Medical Documentation - Clinical Advisor

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 …

Charting Do’s & Don’ts for Health Care …

https://clipboardacademy.org/charting-dos-donts-for-health-care-professionals/

General Charting Guidelines Whether you’re charting by hand or on the computer, there are guidelines for charting best practices that apply to most jobs. Do… Double-check …

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 …

15 Not-So-Obvious Documentation

https://nursemoneytalk.com/blog/charting-tips-for-nurses

Patient charting is important for several reasons: It gives a record of everything that was done regarding that patient’s medical health care. (Ex. past surgeries, past medications …