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Documentation Where you can go wrong…. Andrew Bernard Carl Hatmaker. Document for…. Your patient care (so you can remember) Other members of the healthcare team Establish acuity Hospital billing QA measures For the patient Protection Billing. Event Note. Summary. Date and time
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DocumentationWhere you can go wrong… Andrew Bernard Carl Hatmaker
Document for… • Your patient care (so you can remember) • Other members of the healthcare team • Establish acuity • Hospital billing • QA measures • For the patient • Protection • Billing
Summary • Date and time • Your title and service • Use English • Decision making (impression and plan) most commonly omitted