TY - CHAP M1 - Book, Section TI - Professional Coding and Billing Guidelines for Clinical Documentation A1 - Pohlig, Carol A1 - Manaker, Scott A2 - McKean, Sylvia C. A2 - Ross, John J. A2 - Dressler, Daniel D. A2 - Scheurer, Danielle B. Y1 - 2017 N1 - T2 - Principles and Practice of Hospital Medicine, 2e AB - The medical record of an individual patient serves numerous functions. Ideally, the record should provide a comprehensive historical vehicle promoting excellence in care delivery to a patient, transcending communication barriers, and facilitating care coordination among multiple disparate providers and facilities (such as hospitals). However, the medical record also serves as the basis for a variety of financial, legal, and administrative functions including the documentation for both professional and facility fee reimbursement, quality and safety assessments (including pay for performance), malpractice litigation and disability determinations, and community-based care and public health initiatives. SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/04/16 UR - accessmedicine.mhmedical.com/content.aspx?aid=1137606631 ER -