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Guidelines for Medical Record …

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

    Fundamental charting principles for nurses | NSO

      https://www.nso.com/Learning/Artifacts/Articles/Defensive-Documentation-Steps-Nurses-Can-Take-to-Improve-Their-Charting-and-Reduce-Their-Liability
      Ensure that findings are properly communicated and acknowledged, documenting these actions in the patient’s health information record. Avoid repetitive copying and pasting. …

    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
      Proper medical charting is critical to protecting against legal risk. August 19, 2021. Ryan Rivas, JD. While helpful, the increase in electronic patient information creates …

    Thinking on Paper: Documenting Decision Making | AAFP

      https://www.aafp.org/pubs/fpm/issues/2010/0700/p10.html
      Where medical decision making is concerned, Medicare's Documentation Guidelines for Evaluation and Management (E/M) Services are more striking for what they leave unsaid …

    ED Charting and Coding: Medical Decision Making …

      https://www.aliem.com/charting-and-coding-medical-decision-making/

      Health Care Risk Management: The Importance of …

        https://www.mackenziehughes.com/blog/health-care-risk-management-the-importance-of-documentation/
        You document a patient’s history, complaints, findings on exam, and diagnoses. You keep a record of a patient’s current medications and allergies. You record …

      Risk Management Plan for Medical Devices: A practical …

        https://www.qualitymeddev.com/2021/02/13/risk-management-plan/
        The risk management plan is one of the key document for the risk management process for a medical device manufacturers and it is essential to understand the requirements that are necessary to cover …

      CPT® Evaluation and Management | American Medical …

        https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
        This provision includes revisions to the Evaluation and Management (E/M) office visit CPT® codes (99201-99215) code descriptors and documentation standards that directly address the continuing …

      HIM, Operations, Hospital Chart Completion, …

        https://tenetway.tenethealth.com/policies/compliance/billing-and-coding-compliance/him-operations-hospital-chart-completion-documentation-and-security
        HIM, Operations, Hospital Chart Completion, Documentation, and Security. Completing medical records is a requirement of the facility ’s Medical/Professional Staff …

      The Medical Record | Manual - Risk Management

        https://www.ihs.gov/riskmanagement/manual/manualsection05/
        The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and …



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