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Nurs 522 Advanced Health Assessment Exam 1 Questions And Verified Answers |100% Correct | Already Graded A

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NURS 522 Advanced Health Assessment Exam 1 QUESTIONS AND VERIFIED ANSWERS |100% CORRECT | ALREADY GRADED A List five general principles of documentation that are based on CMS guidelines. - a. The medical record should be complete and legible. b. The documentation of each patient encounter should include the following: • Reason for the encounter and relevant history, physical examination findings, and diagnostic test results • Assessment, clinical impression, or diagnosis • Plan for care • Date and legible identity of the health-care provider c. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. d. Past and present diagnoses should be accessible to the treating and consulting providers. e. The patient's progress, response to and changes in treatment, and revision of

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