Medical Documentation Tips

Ten EHR Strategies for Efficient Documentation | AAFP

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

Rethink your exam room setup. Ideally, you should place the computer where you …

5 Best Practices for Medical Documentation - Clinical …

https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/

Document Your Examination. Failure to document a physical examination is the most …

A complete cheat sheet for clinical documentation

https://www.carepatron.com/blog/clinical-documentation-cheat-sheet

Report critical values - Remember to always report critical values to a nurse within 15 …

Documentation Matters Toolkit | CMS

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

10 Tips for Effective Documentation - MedBridge Blog

https://www.medbridgeeducation.com/blog/2019/11/10-tips-for-effective-documentation/

Documentation Tips for Reducing Malpractice Risk | AAFP

https://www.aafp.org/pubs/fpm/issues/2000/0300/p29.html

Document goals or expected outcomes and specify a time frame for reaching them. Include interval instructions in case of... Complement a concise statement of the agreed plan with …

Medical Documentation Tips - bcbsal.org

https://providers.bcbsal.org/portal/documents/10226/306297/Medical+Documentation+Tips/98b50e9d-816d-464d-a0a7-9fbe11d5438c

Documentation should: • Be legible so that it doesn’t interfere with the ability to code diagnoses. • Only include standard abbreviations or symbols. • Show an apparent …

15 Not-So-Obvious Documentation

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

1. Think Like a Lawyer 2. Stop Double Charting 3. Avoid Inconsistent Charting 4. Document Events As They Happen 5. Keep Paper Handy to Jot Down Notes 6. Avoid …

Clinical documentation | How to document …

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

The basics of clinical documentation Date, time and sign every entry. Although simple, its importance cannot be overstated. The timing of events and reviews...

Documentation Do’s and Don’ts - Medical Liability Insurance

https://www.callcopic.com/docs/default-source/resource-center/newsletters/copic-tips/2017_9/documentationdosdonts.pdf?sfvrsn=1e334f82_4

The most important document in the defense of a medical liability claim is the patient’s medical chart. If the documentation is accurate, objective, legible, timely, …