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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 database lack the force and effect of law, except as authorized by law (including …

Fundamentals of the Legal Health Record and …

    https://library.ahima.org/doc?oid=104008
    1. Identify Relevant Regulations, Standards, and Laws. Based on the committee's clinical ...

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 …

Ethical Standards for Clinical Documentation …

    https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868
    The following ethical standards are based on the core values of the American Health Information Management Association and the AHIMA Code of Ethics. They apply to all …



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