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From papyrus to the electronic tablet: a brief history of …
- https://pubmed.ncbi.nlm.nih.gov/24054954/
- A forerunner of modern medical records first appeared in Paris and Berlin by the early 19th century. Development of the clinical record in America was pioneered in the 19th century …
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 …
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 …
Document Patient History - The Hospitalist
- https://www.the-hospitalist.org/hospitalist/article/123646/document-patient-history
- Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and …
History of medical records - University of Cambridge
- https://casebooks.lib.cam.ac.uk/astrological-medicine/history-of-medical-records
- They built on the work of ancient and medieval physicians whose writings detailed remarkable cases and exceptional cures, and, like natural historians, borrowed …
A History of Medical Records in the Ancient …
- https://synapsemedical.com.au/news/2019/07/15/a-history-of-medical-records-in-the-ancient-world/
- A History of Medical Records in the Ancient World. Medical records have a surprisingly long and illustrious history, stretching back to ancient …
The History of the Patient Record and the …
- https://www.researchgate.net/publication/325122514_The_History_of_the_Patient_Record_and_the_Paper_Record
- Healthcare providers still use different elements of the POMR format using positive terminology of patient goals and objectives, together with more …
Clinical documentation | How to document …
- https://onthewards.org/how-to-document-well/
- Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into …
MEDICAL DOCUMENTATION - SlideShare
- https://www.slideshare.net/doctorrao/medical-documentation
- What is Documentation • Anything written or printed • Relied on as a record of proof for authorized persons • Vital part of professional practice 2. 3. Purposes of …
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