DOCUMENTATION 167

Course overview

*Apply best practices for using abbreviations, addressing legibility, authentication of signatures, and managing the day-to-day flow of your patient records. *Clearly delineate the beginning and end of episodes of patient care, proper recording of these episodes, and boundary discussions with patients. *Locate and utilize the definitions of medically necessary care, and apply it as a differentiator from clinically appropriate care. *Assess documentation across the life cycle of the patient's chart from history to discharge and on through maintenance and wellness care based on live examples demonstrated. *Identify the deficiencies that may be present in your documentation through the eyes of an auditor.