After reading Chapter, Medical Documentation and the EHR, you will complete an outline of the outcome.

Outcomes:

1. Identify the most common documents found in the health record.
2. Understand why complete documentation is important.
3. Discuss health record systems and list the advantages and disadvantages of an electronic health record system.
4. Define the various titles of physicians as they relate to health record documentation.
5. Explain the purpose of Clinical Documentation Improvement (CDI).
6. Explain the reasons that legible documentation is required.
7. Describe signature requirements for documentation.
8. Describe common documentation errors found in health records and define medical necessity.
9. Formulate a procedure for termination of care.
10. Define common terminology related to medical, diagnostic, and surgical services and describe proper documentation for each.
11. Respond appropriately to the subpoena of a witness and records.
12. Identify principles for the retention of health records.
13. Abstract information from the health record to complete a life or health insurance application.
14. Describe the difference between prospective, concurrent, and retrospective review of records.