Nt1330 Unit 2

Accuracy- information must be correct, updated information

Relevance- information relevant to patients healthcare

Completeness- free from omissions

Timeliness- time requirements for completion

Confidentially- no release without patient consent

Explain why medical documentation is required.
"If it's not documented in the medical record then it didn't happen". Documentation is required because it can be used as a form of communication in an office between physicians. Every individual record is organized to ensure that medical records are easily accessible for review and available when needed. It is an essential component of quality care

List the principles of documentation.
The principles of documentation are clear and specific. They