Want this question answered?
Quotation marks should be used when indicating a patient's exact words on a medical record.
No deletions should be made, as the medical record is also a legal document. But an amending notation should be made and added to the medical record.
The medical record is a legal document.
Most movie titles should appear in italics, as it is a large work or publication or art. However, if the piece of art or work is small of a part of the larger work it should be enclosed in quotation marks.
Medical records are confidential. They should only be released after the patient has signed a release form.
How long should a medical record be retained
a medical assistant should never code a patient as having what unless its is documented in medical record
It should be enclosed in quotation marks.
Medical records should be kept for as long as required based on the type of record, and federal/state laws.
Absolutely yes.
b. At the time the event occurs
Date and time should be included on all entries into the record. A person's full name and other identifiers (i.e., medical record number, date of birth) should be included on all records