Page 7 - Risk Reduction Series - Documentation Essentials (Part One)
P. 7
Table of Contents
PART ONE 9
Introduction ..................................................................................................9
General Documentation Guidelines .................................................... 15
Unique to Paper Charts ................................................................................17
The Medical Record in the Office Setting Should Include ....17
The Objective is to be Objective .....................................................21
Accurate and Complete ...................................................................... 25
Ensure Quality Documentation ..............................................................26
Basic Guidelines for Documenting Medications .........................27
The Importance of Documenting Family History ......................29
Timely Documentation ................................................................................30
After-Hours Calls Documentation ........................................................32
Amending the Record ................................................................................. 34
Avoid Jousting or Finger-Pointing ..................................................41
