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Regulations and guidelines regarding who is authorized to document in a patient record can typically be found in the Health Insurance Portability and Accountability Act (HIPAA) regulations, as well as state-specific medical practice acts and licensing boards. Additionally, healthcare organizations often have their own policies and procedures that outline documentation responsibilities. Professional associations, such as the American Health Information Management Association (AHIMA), also provide resources and best practices related to documentation standards.

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3mo ago

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