what is documentation
Documentation: It is recognized as an instance or the act for authenticating or furnishing with documents or the providing of documents in substantiation. The written record is the mechanism through which the health-care expert is held liable for the medical care provided to the patient.
Ex: During physical therapy:
The quality of patient care is recorded in documentation, and it creates the capability to copy that type of care during the treatment procedure.
Documentation constructs a lawful report of patient care and treatment and facility and treating therapist and care for the safety of the patient.
Documentation delivers the base for a suitable reimbursement for skilled patient care
What are the examples of " deficiencies in the audit documentation" ?
What are the risks of inadequate audit documentation?
1. Explain what a documentation audit is and the documentation audit cycle. 2. Explain the concept of a business associate under HIPAA. 3. Summarize the privacy standards of HIPAA and ARRA/HITECH regarding business associates. 4. Describe the key elements of a business plan for an independent consultant. 5. Explain the concept of a business associate under HIPAA.
What are some examples of implementation in nursing documentation ?
Discuss some of the important features of audit documentation and what are the risks of inadequate audit documentation.
What is the correct order in the patient education process? A. Assessment, planning, implementation, documentation, evaluation B. Planning, assessment, implementation, documentation, evaluation C. Assessment, planning implementation, evaluation, documentation D. Assessment, implementation, planning, evaluation, documentation E. Evaluation, assessment, implementation, documentation, planning
what are the four (4) common types of WHS documentation?
In a 3 paragraph synopsis describe why it is important to have proper documentation, what happens if there are documentation errors, and what kind of outcomes come from documentation errors. Cite all material in APA format.
what are some security issues regarding the computerized documentation system
When documentation deficiencies are identified, educate the physicians on improving their documentation. Emphasize the initial importance of documentation by showing examples of how poor documentation can lead to adverse consequences. When clarification or additional information is obtained from the physician for coding purposes, make sure this information is subsequently documented in the medical record. Most coders are familiar with the coding principle of "query the physician" when documentation affecting code assignment is unclear or incomplete. Too often, the physician answers...