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What happpens if something is not documented in a medical record?
Wiki User
∙ 13y ago
There would be no proof of anything.
Wiki User
∙ 13y ago
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Who documented HPI in the medical record?
The HPI may be documented by the medical assistant or nurse, and then confirmed and refined by the clinician.
If a code is not documented in medical records the medical assistant should never code a patient as having what?
a medical assistant should never code a patient as having what unless its is documented in medical record
How is evolution documented?
Evolution is documented in both realtime experimental and observational data, as well as in the fossil and genomic record.
What is a note that is added to the record after an original note has been documented?
A postscript.
What are the importance of medical record keeping?
The importance of medical record keeping is keeping a treatment record of a patient that allows medical professionals to know the patient's past
What is the medical term meaning record of the eardrum?
Tympanogram is the medical term for a record of the eardrum.
You work for medical record review how do you handle wrong medical codes?
If the medical record naratted a wrong diagnosis it will reflect in doing medical coding
What is the medical term meaning RECORD of the LUNG?
A pneumogram is the medical term meaning record of the lung.
Why should a recording in the medical record never be erased or abliterated?
The medical record is a legal document.
What is the medical term meaning record of a breast?
Mammogram is the medical term meaning record of a breast.
A medical record is an example of?
A person's (patient) medical record is the history of what medical illnesses and the medicine prescribed the person received to date.
What is the only information documented in the may be considered in determining level of service?
patient record
