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Identify the critical purposes of the clinical record. |
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Define the characteristics of a clinical record entry
that create an effective and legal entry. |
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Examine and compare different styles and models of
clinical record entries. |
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List trends in health care today that impact written
communication in the clinical record. |
|
Explain how legal and reimbursement problems occur due to
omitted, altered, incorrect or incomplete clinical record entries. |
|
List characteristics of documentation that increase both
legal and reimbursement risk. |
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Differentiate between chart entries that do and do not
meet the criteria of an effective and legal entry. |
