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Florida Handbook: Documentation

WHAT ITEMS SHOULD BE PRESENT IN A 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 affect the outcome. Clear and comprehensive documentation also enables a physician to plan and evaluate treatments and to communicate with other providers. Guarding the integrity of office practice medical records is the responsi...
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