The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), ... This appendix provides excerpts from the Medicare Conditions of Participation. (CoP) concerning medical records and plans of care for health care providers. The health record is a chronological documentation of health care and medical treatment given to a patient by professional members of the health care team and ... By AHIMA Work Group · 2013 · Cited by 9 ? Ensuring Documentation Integrity. Documentation integrity involves the accuracy of the complete health record. It encompasses information governance, patient ... ... countersign entries made by unregistered healthcare professionals such as healthcare assistants or students. ... Ensure that all patient records ... The approach to record keeping that courts of law adopt tends to be that 'if it is not recorded, it has not been done'. Good record keeping shows how ... The clinical records must be completely, promptly, and accurately documented, readily accessible, and systematically organized to facilitate retrieval and ... Once deemed competent, there is no further requirement for the supervising allied health professional to countersign AHA entries. Please note: Depending on the ... By JG Nkera-Gutabara · 2020 · Cited by 12 ? Medical prescription writing is legally and professionally regulated in order to prevent errors that can result in patients being harmed. This ... * Maintain accurate, honest records of patient care and business activities, which include following procedures to correct and amend records and to make late ...