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Outline of the treatment plan designed to remedy the patient's condition, which includes instructions to the patient's orders for medications, diagnostic tests, or therapies The following 21 elements reflect a set of commonly accepted standards for medical record documentation. The risks to the patient from missing clinical documentation is that their treatment plan will take longer due to not knowing anything about the patient’s history.

Direct referred as covered entitles includes hospital, clinics, nursing, assisted living facilities, home health agencies, physicians, dentists, and alternative medicines. Consistent, current and complete documentation in the medical record is an essential component of quality patient care An individual has a right to access phi about themselves in a medical record or other designated record set maintained by a covered entity, regardless of the date the information was created or whether the information is maintained onsite, remotely, or is archived.

An appropriately documented medical record can reduce many of the challenges associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

A patient presents to the emergency room with severe shortness of breath, extreme lethargy, and intermittent loss of consciousness The patient is unaccompanied and unable to provide past history of diagnoses or treatments As technology advances and health care providers increasingly communicate more informally, plaintiff’s malpractice attorneys are requesting emails and electronic communications that do not form part of the patient’s traditional medical record.

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