Different types of medical record documentation
Assignment Purpose:
Gain an understanding about different types of medical record documentation and associated legal issues of an EHR
Assignment Description
Step One: Select three types of medical record documentation that you would expect to see in an EHR (e.g. H&P, operative report, labs, nursing documentation, discharge summary, etc.).
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Step Two: Locate an article, legal case, report, white paper or other resources that discusses a legal issue associated with the types of documentation that you selected. (NOTE: you may have to locate more than one article to cover all three types of documentation.)
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