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 a cost for the hospital system thorough documentation of all medical issues and treatments is therefore crucial for hospital funding particularly in discharge summaries. Medical records from outside source copies of records from an outside source may be used if they support endpoints inclusion exclusion criteria or adverse events attempts to obtain medical records should be recorded in the research chart questionnaires documentation must reflect who completed the questionnaire in compliance with the protocol. Designate someone in your practice to educate themselves on the importance of accurate clinical documentation and how accuracy can impact both patients and the practice in addition to becoming the go to person for documentation clarification this individual can work with the physicians to create measurable goals for documentation improvement. Commonly accepted standards for medical record documentation 1 each page in the record contains the patients name or id number 2 personal biographical data include the address employer home and work telephone numbers and marital status 3 all entries in the medical record contain the authors identification author identification may be a handwritten signature
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