RT Book, Section
A1 Manaker, Scott
A1 Pohlig, Carol
A2 McKean, Sylvia C.
A2 Ross, John J.
A2 Dressler, Daniel D.
A2 Brotman, Daniel J.
A2 Ginsberg, Jeffrey S.
SR Print(0)
ID 56192829
T1 Chapter 28. Clinical Documentation for Hospitalists
T2 Principles and Practice of Hospital Medicine
YR 2012
FD 2012
PB The McGraw-Hill Companies
PP New York, NY
SN 978-0-07-160389-8
LK accessmedicine.mhmedical.com/content.aspx?aid=56192829
RD 2024/04/19
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).  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.