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Medical record keeping: clarity, accuracy, and timeliness …
- https://www.bmj.com/content/348/bmj.f7716
- Wedad Abdelrahman and Abdelrahman Abdelmageed explain why it is important that these records are well maintained. Medical records are a fundamental part of a doctor’s duties in providing patient care. As well as handwritten clinical notes, medical …
Medical Records, Privacy, Accuracy, and Patients' …
- https://www.verywellhealth.com/medical-records-privacy-accuracy-and-patients-rights-2615509
- HIPAA addresses the privacy and security of patient medical records, and the remedies available to …
Complying With Medical Record Documentation …
- https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet
- Learn about proper medical record documentation requirments; how to provide accurate and supportive medical record documentation. Download the …
How accurate is the medical record? A comparison of …
- https://academic.oup.com/jamia/article/27/5/770/5824779
- Accurate medical records are not only important for keeping medical costs in line with services provided, but also critical for providing high-quality, high …
What Is Clinical Documentation Improvement (CDI)?
- https://www.aapc.com/clinical-documentation-improvement/
- A clinical documentation improvement program is a process designed and implemented with the purpose of achieving accurate and thorough medical record …
Electronic Health Record Data Governance …
- https://www.himss.org/resources/electronic-health-record-data-governance-and-data-quality-real-world
- Domain: Patient Safety Real-World Context: About 80% of allergies in the medical record are recorded incorrectly, while 30% are just written words (no code or …
Medication adherence, medical record accuracy, and …
- https://pubmed.ncbi.nlm.nih.gov/28957369/
- In a retrospectively tested 821-patient cohort representing U.S. adults, we found that 46% of medications assessed were detected in patients as prescribed in the …
Integrity of the Healthcare Record: Best …
- https://flbog.sip.ufl.edu/risk-rx-article/integrity-of-the-healthcare-record-best-practices-for-ehr-documentation/
- Ensuring Documentation Integrity Documentation integrity involves the accuracy of the complete health record. It encompasses information governance, patient …
How do you make sure medical records are accurate and complete?
- https://knowledgeburrow.com/how-do-you-make-sure-medical-records-are-accurate-and-complete/
- An electronic health record, or EHR, is set up to ensure that medical charts are complete and accurate. Think of it as a digital version of a patient’s paper medical …
How accurate is the medical record? A comparison of …
- https://pubmed.ncbi.nlm.nih.gov/32330258/
- How accurate is the medical record? A comparison of the physician's note with a concealed audio recording in unannounced standardized patient encounters The …
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