The Medical Record

Posted by Kyle Bridgford - January 15, 2017


  • is lawful documentation
  • consists of a patient’s medical history
  • chronologically papers a client’s care
  • permits physicians to prepare and also evaluate a person’s care
  • offers continuity in treatment
  • allows all doctors associated with a person’s like interact with each other
  • gives proof of care given in lawful situations
  • aids in cases testimonial and also repayment
  • helps in meeting certification demands

Centers for Medicare as well as Medicaid Services (CMS) policies relating to paperwork

Documentation MUST consist of:

  • proof of a physical exam carried out no unique article than 7 days before admission or within 48
  • hrs of admission
  • arise from individual consultations as well as the findings from such assessments
  • all orders, development notes, medicine documents, radiology procedures as well as outcomes, laboratory results,
  • as well as important signs
  • the confessing medical diagnosis
  • a client’s medical problems
  • any kind of relevant risk factors


The S.O.A.P. Model

Subjective info includes details provided straight by the client, such as how they are feeling, their opinions on their care, as well as why they made the visit. It stands for the individual’s viewpoint of their condition.

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