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Wiki EHR entry for EACH visit

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AprilSueMadison

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It has come to my attention that sometimes our providers will see a patient for severe bleeding (a day after surgery) or to remove a deep suture that has worked it way out....without checking the patient in and without creating a medical record entry.


I'm looking, but can someone provide me with links to a rule or guideline that says we need to have an entry for every visit...not matter how small they feel it is? Thank you!
 
Medicare must have something, but I don't know where it is. Your state law may also address the issue. (Florida Statutes Section 458.331(1)(m) says "a physician may be disciplined for "[f]ailing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered, and reports of consultations and hospitalizations.")

Your malpractice insurer probably can advise you of their position on the matter, as well.
 
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