Medical Documentation

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Commonly Asked Questions about Medical Documentation

What are the 10 Cs of medical documentation?

writing or presentation, namely, clear, complete, concise, considerate, correct, creative, credible, current, and more.

What are the types of medical documents?

Types of Medical Records EHR (Electronic Health Records) EHRs are comprehensive digital records that consolidate your health information in one secure location. PHR (Physical Health Records) Medical History Records. Medication Records. Immunization Records. Laboratory and Test Results. Progress Notes. Surgical Records.

How to document medical notes?

They should include: 1) All relevant clinical findings. 2) A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. 3) A record of the information given to patients. 4) A record of any drugs prescribed or other investigations or treatments performed.

What is a medical documentation?

Documentation typically reports why the patient was seen, what assessment or treatment was provided, clinical findings (e.g., diagnoses), and what (if any) treatment was recommended and provided in a way that justifies the assigned diagnosis and procedure codes (see Coding for Reimbursement).

What does medical documentation refer to?

Medical documentation refers to the act of authenticating patient care with factual or substantial support, including content, editing, procedural, and style issues.

Overview What is medical documentation?

Documentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patients history so they can continue to provide the best possible treatment for each individual. 4 Reasons Why Proper Medical Record Documentation Is Vital scphealth.com blog think-with-your-ink- scphealth.com blog think-with-your-ink-

What is the meaning of medical document?

: a record of a patients medical information (as medical history, care or treatments received, test results, diagnoses, and medications taken)

What counts as medical documents?

Typical medical records include: Patient identification, contact information, and date of birth. Billing and health insurance details. List of current and chronic ailments and diagnoses.

Definition What is a medical document?

The basics of clinical documentation Date, time and sign every entry. Write your name and role as a heading and the names and roles of all others present at the encounter. Make entries immediately or as soon as possible after care is given. Be legible. Be thorough, accurate, and objective. Maintain a professional tone. Clinical documentation | How to document medical information well onthewards.org how-to-document-well onthewards.org how-to-document-well