explain how to maintain records so that they are up to date,complete,accurate and legible.
electronic or paper documents containing factual information regarding a patient’s health status and the corresponding medical opinions based on that information
A patient’s medical record serves multiple functions. [ First, it provides a method of clinical communication and care planning among healthcare practitioners, employers, payers and patients. Second, the medical record indicates
the basis for evaluating the adequacy and appropriateness of care. The medical record must include all supporting documentation for the reimbursement of services provided. (i.e., Results from ordered tests including, but not limited to x-rays, labs, communication from other providers involved in the patient’s care, etc.) In addition the medical record provides protection of the legal interests of the patient, facility and healthcare practitioners. Finally, the medical record is utilized as clinical data for the purpose of research and education. ]
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