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PDF Guide to Clinical Documentation 2e, Guide to Clinical Documentation 2e Free Download, Debra D Sullivan epub Guide to Clinical Documentation 2e, Free Download Guide to Clinical Documentation 2e.

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To introduce you to this world of academic writing, in this chapter I suggest that you should focus on five hierarchical characteristics of good writing, or the “5 Cs” of good academic writing, which include Clarity, Cogency, Conventionality, Completeness, and Concision.

Providers must practice and refine their ability to create documentation that meets the seven criteria for good clinical notetaking: the documentation must be legible, reliable, precise, complete, consistent, clear, and timely, AHIMA says.

Providers must practice and refine their ability to create documentation that meets the seven criteria for good clinical notetaking: the documentation must be legible, reliable, precise, complete, consistent, clear, and timely, AHIMA says.

An electronic health record (EHR) contains patient health information, such as: Administrative and billing data. Patient demographics. Progress notes. Vital signs. Medical histories. Diagnoses. Medications. Immunization dates.

The Dos & Don'ts of Documentation DON'T copy information. DON'T use vague terms. DON'T use P.U.T.S. in place of the patient's signature. DO support medical necessity. DO be specific. DO be truthful. DO document treatment results.

Be clear, legible, concise, contemporaneous, progressive and accurate.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232