PURPOSES
CHARACTERISTICS
MISCELLANEOUS
TYPES
WHATEVER
100
PROVIDES THIS IF IT BECAME ADMISSABLE IN A COURT OF LAW
What is LEGAL PROTECTION
100
ALL REQUESTED INFORMATION
What is MUST BE INCLUDED
100
LOL, OMG, AMT,
What is ABBREVIATIONS
100
DETAILED WRITTEN NOTES
What is NARRATIVE
100
PHR
What is PERSONAL HEALTH RECORD
200
REGULATORY AGENCIES REQUIRE THIS
What is ENSURES COMPLIANCE
200
OBESERVED, DONE OR HEARD
What is FACTUAL DATA
200
WHEN AN ERROR OCCURS
What is DRAW A LINE THRU IT
200
CBE
What is CHARTING BY EXCEPTION
200
HIPPA
What is HEALTHINSURANCE PORTABILITY AND ACCOUNTABILITY ACT
300
PREVENTS REPETITION AND UNNECESSARY PROCEDURES
What is IMPROVES COST CONTROL
300
CORRECT DATA ON EVERY PAGE
What is PT. NAME AND NUMBERS
300
NEVER EVER DO THIS BEFORE YOU DO IT
What is CHART IN ADVANCE
300
ORGANIZED AROUND THE PATIENTS HEALTH PROBLEMS
What is PROBLEM ORIENTED CHARTING
300
ALL RECORDS MUST INCLUDE
What is DATE AND TIME
400
PROOF THAT CARE WAS PROVIDED
What is DECREASES DENIALS FROM INSURANCE COMPANIES
400
EASILY READ
What is LEGIBLE
400
WHAT YOU CHART ON
What is PROGRESS NOTES
400
LAPTOP
What is COMPUTERIZED CHARTING
400
H & P
What is HISTORY AND PHYSICAL
500
DATA THAT ALLOWS HEALTH CARE PROFESSIONALS TO BASE THEIR APPROACH TO THE PATIENT
What is MEDICAL DOCUMENTATION
500
NOT STATING OPINIONS
What is OBJECTIVE
500
EMR
What is ELECTRONIC MEDICAL RECORDS
500
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN
What SOAP CHARTING
500
REFERS TO THE COLLECTION OF ALL DOCUMENTS
What is THE MEDICAL RECORD
M
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