Medical records documentation date 2014 12 01 providers should submit adequate documentation to ensure that claims are supported as billed for more information please refer to complying with medical record documentation requirements fact sheet pdf and the cert outreach education task forces webpage contact us home a federal government website managed and paid for by the us . 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. O medical record documentation is required to record pertinent facts findings and observations about a veterans health history including past and present illnesses examinations tests treatments and outcomes o the medical record documents the care of the patient and is an important element contributing to high quality care. What to document medical records content physicians must ensure that patient identification ie name date of birth ohip number gender information and contact information ie telephone number and address are captured in all medical records 10 physicians must date each entry in the medical record. Dr thompson cites four reasons why its vital to properly document patients medical records 1 communicates with other health care personnel documentation communicates the quality of clinical care that providers are delivering to patients and serves as a means to facilitate the continuum of care from em to hm and beyond 2 reduces risk management exposure documentation mitigates risks and reduces the chance of malpractice a well documented record can help alleviate liability
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