Clinical Medicine Midterm Exam questions and answers Graded A+

Clinical Medicine Midterm Exam questions and answers Graded A+ medical and legal considerations of documentation -documents the details of the patient's complaint, evaluation and treatment -establishes your credibility as a health care provider -primary means of communication with other providers -all records are legal documents -provides evidence that appropriate care was given -memory aid: detailed record of what occurred (only what is written happened) centers for medicare and medicaid services (CMS) nation's largest payers for healthcare services that has guidelines for documentation general principles of documentation 1. the medical record should be complete and legible 2. the documentation should include: reason for the encounter and relevant history, PE findings and diagnostic results; assessment and clinical impression; plan for care; date and name of provider 3. if not documented, the rationale for diagnostic studies and ancillary care should be inferred 4. past and present diagnoses should be accessible to the treating/consulting providers 5. health risk factors should be identified 6. the patient's progress, response to and changes in treatment should be documented 7. the diagnosis and treatment codes (for billing) should be supported by the documentation electronic medical records longitudinal electronic record of patient health information generat