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BOOK SUMMARY :

Documentation of medical records introduction in a continuous care operation it is critical to document each patients condition and history of care to ensure the patient receives the best available care the information must be passed among all members of the interdisciplinary team of caregiverscomplying with medical record documentation requirements mln fact sheet page 3 of 7 icn 909160 april 2017 third party additional documentation requests upon request for a review it is the billing providers responsibility to obtain supporting documentationin the legal system documentation is regarded as an essential element extending the risk management dimension failure to document relevant data is itself considered a significant breach of and deviation from the standard of care 13 of course protection from legal jeopardy is far from the only reason for documentation in clinical care the patients record provides the only enduring 1292015 1 your medical documentation matters presentation objectives at the conclusion of this presentation participants will be able to identify medicaid medical documentation rulespage 2 of 23 claim is expected to be in the members medical record and be available for review the provider submitting the claim is responsible for providing upon request all pertinent information and records

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