Proper Charting Medical Records

Set Forth the Basics of Good Medical Record …

https://www.aapc.com/blog/28703-set-forth-the-basics-of-good-medical-record-documentation/

CMS provides guidelines to help ensure every patient’s health record contains quality documentation. General principles of medical record documentation for reporting medical and surgical services for Medicare payment include (when applicable to …

Importance of Documentation | Office of Inspector …

https://oig.hhs.gov/newsroom/oig-podcasts/importance-documentation/

Good documentation is important to protect your patients. Good documentation promotes patient safety and quality of care. Complete and accurate …

Documentation Matters Toolkit | CMS

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation

Guidelines for Medical Record Documentation

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

All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. 4. All entries are dated. …

5 Best Practices for Medical Documentation - Clinical …

https://www.clinicaladvisor.com/home/topics/practice-management-information-center/5-best-practices-medical-documentation/

Document Your Examination. Failure to document a physical examination is the most …

Charting 101: making sure your documentation is on time …

https://www.todayshospitalist.com/Charting-101-making-sure-your-documentation-is-on-time-and-legible/

RULE #1: Get it done on time. Physicians should aim to complete charts immediately after treatment when details are still fresh. Most hospitals set time limits for when …

Charting Do’s & Don’ts for Health Care …

https://clipboardacademy.org/charting-dos-donts-for-health-care-professionals/

Record the proper date and time. Write down the date, time, message, response, and any other meaningful details when you receive phone calls. Chart preventative measures, like the use of …

Clinical documentation | How to document …

https://onthewards.org/how-to-document-well/

The medical record is a way to communicate treatment plans to other providers regarding your patient. This ultimately ensures the highest quality of patient care. Conversely, poor records can …

15 Not-So-Obvious Documentation

https://nursemoneytalk.com/blog/charting-tips-for-nurses

Patient charting is important for several reasons: It gives a record of everything that was done regarding that patient’s medical health care. (Ex. past surgeries, past medications received and so forth) If the …

Medical Charting Best Practices for Nurses - MOS …

https://www.mosmedicalrecordreview.com/blog/medical-charting-best-practices-for-nurses-to-avoid-malpractice-risk/

Be Careful about Altering the Medical Record: Any alteration made in the record must include the date and time of the change made. Care must be taken not to obliterate the original …