Medical providers are required to record relevant facts, observations, and findings about a patient’s health history. Entries include past and present illnesses, examinations, testing, treatment, and outcomes. The medical record contains chronological documentation of each patient encounter and is integral to delivering high-quality care. As defined by CMS, the medical record facilitates:
• The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment and to monitor his/her health care over time
• Communication and continuity of care among physicians and other health care professionals involved in the patient’s care
• Accurate and timely claims ...
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