Page 7 - Part One Risk Reduction Series - Documentation
P. 7
TABLE OF CONTENTS
PART ONE .................................................................................................... 9
Introduction ................................................................................................... 9
General Documentation Guidelines ............................................... 14
The Medical Record in the Office Setting Should Include .. 17
The Objective is to be Objective ................................................... 20
Accurate and Complete ...................................................................... 25
Basic Guidelines for Documenting Medications ..................... 26
The Importance of Documenting Family History ................... 27
Timely Documentation ........................................................................ 29
After-Hours Calls Documentation .................................................. 31
Amending the Record ......................................................................... 33
Avoid Jousting or Finger-Pointing ............................................... 40
