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After reading Chapter, Medical Documentation and the EHR, you will complete an outline of the outcome. Outcomes: Identify the most common documents found in the
After reading Chapter, Medical Documentation and the EHR, you will complete an outline of the outcome.
Outcomes:
- Identify the most common documents found in the health record.
- Understand why complete documentation is important.
- Discuss health record systems and list the advantages and disadvantages of an electronic health record system.
- Define the various titles of physicians as they relate to health record documentation.
- Explain the purpose of Clinical Documentation Improvement (CDI).
- Explain the reasons that legible documentation is required.
- Describe signature requirements for documentation.
- Describe common documentation errors found in health records and define medical necessity.
- Formulate a procedure for termination of care.
- Define common terminology related to medical, diagnostic, and surgical services and describe proper documentation for each.
- Respond appropriately to the subpoena of a witness and records.
- Identify principles for the retention of health records.
- Abstract information from the health record to complete a life or health insurance application.
- Describe the difference between prospective, concurrent, and retrospective review of records.
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