Documentation Where you can go wrong…

Jan 11, 2026

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This document serves as a comprehensive guide for healthcare professionals to enhance patient care through precise documentation. It emphasizes the importance of remembering key details about patients, collaborating with other healthcare team members, establishing acuity, and understanding hospital billing processes. Additionally, it highlights crucial QA measures and protections for patients, alongside clear billing event note summaries. To optimize decision-making and improve patient outcomes, focus on important elements often overlooked, such as documentation of impressions and plans.

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Documentation Where you can go wrong…

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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

Event Note
Summary • Date and time • Your title and service • Use English • Decision making (impression and plan) most commonly omitted

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Documentation Where you can go wrong…

Documentation Where you can go wrong…

Presentation Transcript

by D. Fisher

The 1-2-3 of Electronic Postage Documentation

MLA Documentation

View Based Documentation of Software Architectures from “views and beyond “ by Clements and lots of people

HAPTER 3

Evidence-based chiropractic and documentation

9: Communications and Documentation

Audit Evidence and Documentation

Kant’s Categorical Imperative and Euthanasia

EVALUATION &amp; MANAGEMENT SERVICES Documentation and Coding Guidelines

The Health of the Economy What is wrong and what can be done?

Evaluating Evidence in Medicine: What Can Go Wrong?

Morality and Consequences

INTRODUCTION OF THE STANDARDISED INITIAL ASSESSMENT, CARE PLANNING AND REFERRAL DOCUMENTATION

Managing The Leverage Cycle and What’s Wrong with Macroeconomic Models

Semester 1 CHAPTER 8 Le Chi Trung

Lesson #8 Evidence Gathering &amp; Documentation

E/M Documentation &amp; Coding

Survey Documentation and Analysis (SDA)

Documentation and Communication

ASEAN GMP TRAINING MODULE DOCUMENTATION

Equitable Services to Private Nonprofit (PNP) Schools

EVALUATION & MANAGEMENT SERVICES Documentation and Coding Guidelines

Lesson #8 Evidence Gathering & Documentation

E/M Documentation & Coding