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Medical Record Documentation and Legal Aspects
- https://www.rn.org/courses/coursematerial-215.pdf
- Documentation is a form of communication that provides information about the healthcare client and confirms that care was provided. Accurate, objective, and complete documentation of client care is required by both accreditation and reimbursement …
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 …
Legal Process and Electronic Health Records - AHIMA
- https://library.ahima.org/doc?oid=59559
- The custodian of an electronic health record (EHR) has the same concerns as the custodian of a paper health record when the record becomes involved in the legal …
Medical Record Documentation and Legal Aspects for …
- https://ceufast.com/course/documentation-for-nursing-assistants
- Introduction. Certified Nursing Assistants (CNAs) play a very important role in Long Term …
Medical Record Documentation and Legal Aspects …
- https://lms.rn.com/courses/1745/MedRecDoc_LegalAspects_CNA.pdf
- Your patient's medical record is a legal document that tells the story of his encounter with you and other healthcare professionals. It should provide a complete and accurate …
Medical Record Documentation and Legal Aspects
- https://floridatrainingcenter.org/courses/medical-record-documentation-and-legal-aspects/
- The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s …
Proper medical charting is critical to protecting against legal risk
- https://www.physicianspractice.com/view/proper-medical-charting-is-critical-to-protecting-against-legal-risk
- Today's electronic medical records and corresponding information systems provide a greater wealth of patient data than what was typically included or available in …
Clinical documentation | How to document …
- https://onthewards.org/how-to-document-well/
- A medical record is a legal document. So, understand that what you write is memorialised permanently. In the case of any legal proceedings, documentation is …
NURSING | Free NURSING.com Courses
- https://nursing.com/lesson/fund-03-01-legal_aspects_of_documentation
- Overview Legal Aspects of Documentation Part of Patient’s Medical Record Record in Real Time Falsifying Documentation Subject to Litigation, Audit and Review Nursing …
Legal and medical nursing aspects of documentation, …
- https://pubmed.ncbi.nlm.nih.gov/8524009/
- Legal and medical nursing aspects of documentation, recording and reporting. This article deals with the importance of documentation, recording and reporting as a means of …
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