Identify the critical purposes of the (clinical) medical record.

Define the characteristics of a (clinical) medical record entry that create an effective and legal entry.

Examine and compare different styles and models of (clinical) medical record entries.

List trends in health care today that impact written communication in the (clinical) medical record.

Explain how legal and reimbursement problems occur due to omitted, altered, incorrect or incomplete documentation..

List characteristics of clinical or nursing documentation that increase both legal and reimbursement risk.

Differentiate between chart entries that do and do not meet the criteria of an effective and legal entry.