Tips Proper Medical Documentation

Documentation Matters Toolkit | CMS

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

Writing an Effective Patient Note with Documentation …

https://www.himss.org/resources/writing-effective-patient-note-documentation-guidelines

10 Tips for Effective Documentation - MedBridge Blog

https://www.medbridgeeducation.com/blog/2019/11/10-tips-for-effective-documentation/

Guidelines for Medical Record Documentation

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

10. The history and physical examination identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints. 11. Laboratory and other …

Clinical documentation | How to document medical …

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

The basics of clinical documentation Date, time and sign every entry. Although simple, its importance cannot be overstated. The timing of events and reviews... Although simple, its importance cannot be …

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 …

15 Not-So-Obvious Documentation & Charting Tips for …

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

1. Think Like a Lawyer 2. Stop Double Charting 3. Avoid Inconsistent Charting 4. Document Events As They Happen 5. Keep Paper Handy to Jot Down Notes 6. Avoid Charting Ahead of Time 7. Avoid Emotional or …

10 Nursing Documentation Tips (And Why It's Important)

https://www.indeed.com/career-advice/career-development/nursing-documentation-tips

10 nursing documentation tips 1. Take notes in real time. Due to the various tasks you may be responsible for and the number of patients you may... 2. Take HIPAA …

25 Legal Dos and Don'ts of Nursing Documentation …

https://www.thehealthlawfirm.com/uploads/25%20Legal%20Tips%20For%20Nursing%20Documentation.pdf

4. Don’t diagnose patients. Nurses formulate nursing diagnoses in their care planning, but in everyday progress charting it is not good to speculate about possible medical diagnoses …