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Documentation Where 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

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documentation where you can go wrong

DocumentationWhere you can go wrong…

Andrew Bernard

Carl Hatmaker

document for
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
summary
Summary
  • Date and time
  • Your title and service
  • Use English
  • Decision making (impression and plan) most commonly omitted