Delaware Handbook: Documentation

WHAT INFORMATION SHOULD BE STORED IN THE PATIENT’S MEDICAL RECORD? The importance of careful and accurate documentation in the medical record cannot be overstated. In a malpractice lawsuit, the medical record is an essential element of your defense, and its contents may impact the outcome of the case. Clear and comprehensive documentation also enables the physician to plan and evaluate treatments and to communicate with other providers. Guarding the integrity of a practice’s medical records is the responsibility of the physician(s). Policies and procedures should govern how and when documentation occurs in your office. The following is a list of recommended medical record components. An electronic medical record (EMR) may include...
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