Vague Medical Documentation

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Best documentation practices for diagnosis coding - Humana

https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=2570646

Medical record documentation of patient diagnoses that is clear, concise and described to the highest level of specificity facilitates: ... Vague: “Patient is here for hospital follow-up.” …

Nursing Documentation - Nursing On Point

https://nursingonpoint.com/clinical-resources/documentation-laws-regulations/nursing-documentation/

Documentation is a legal record. Documentation is not merely “record keeping”; the documentation that comprises a patent’s medical record is also a legal document. …

Charting Disruptive Patient Behaviors: Are You Objective?

https://allnurses.com/charting-disruptive-patient-behaviors-are-t512139/

This is a great article and reminder that quality trumps quantity ANY day; objectivity WINS with documentation, even if we don't want to …

Nursing Documentation: What to Write and What to …

https://nprush.com/nursing-documentation-what-to-write-and-what-to-avoid-writing/

1. Be objective. This means if you personally saw it, then you can document it. When documenting an assessment, only write what you heard, saw, or felt …

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 …

Medical Record Documentation and Legal Aspects …

https://lms.rn.com/courses/1745/MedRecDoc_LegalAspects_CNA.pdf

The purpose of this course is to present key topics related to CNA’s documentation for medical records. After successful completion of this course, you will be able to: 1. Explain …

How To Handle Insufficient Medical Documentation in …

https://www.hrlegalist.com/2014/08/how-to-handle-insufficient-medical-documentation-in-support-of-an-employees-ada-accommodation-request/

Workplace accommodation issues under the Americans with Disabilities Act (ADA) can be tricky to navigate especially if the employee’s supporting medical documentation is insufficient. This often occurs in situations …

Vague Medical Documentation | Day of Difference

https://dayofdifference.org.au/v-medical/vague-medical-documentation.html

The missing documentation included: • Medical necessity documentation • A Physician Certification Statement • Required signatures. Documentation — Legible. Medicaid …

Vague Definition & Meaning - Merriam-Webster

https://www.merriam-webster.com/dictionary/vague

vague: [adjective] not clearly expressed : stated in indefinite terms. not having a precise meaning.

Did I Write That? - FADONA

https://www.fadona.org/pdf-forms/FADONA_Speaker_PPTs-Slide-by-Slide/113.pdf

DOCUMENTATION “The majority of improper payments for SNF services were due to insufficient documentation errors. Providers of SNF services are required to submit …

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