Medical Documentation
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history, including past and present illnesses, tests, labs, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality safe care.
Discuss your State Board of Nursing nurse practitioner documentation guidelines (state is PA) and follow up and how this can affect your level of reimbursement in the clinical setting as well as patient care and safety.
5 References less than 5 years