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Policy #1402 Attachment #2 MONTANA MENTAL HEALTH NURSING CARE CENTER 800 CASINO CREEK DRIVE LEWISTON, MONTANA 59457 (4065387451) NOTICE OF TRANSFER OR DISCHARGE (Residents Name) (Date) (Nursing Facility
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Begin by gathering all necessary information such as the patient's personal details, including their full name, date of birth, address, and contact information.
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Next, record the patient's medical history, including any pre-existing conditions, previous surgeries, allergies, and current medications.
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Document the reason for the medical visit or consultation, along with any symptoms or complaints reported by the patient.
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Record the results of any physical examinations, laboratory tests, or diagnostic procedures conducted during the visit.
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Include a detailed description of the diagnosis or medical condition, along with any recommended treatment plans, medications prescribed, or follow-up instructions given to the patient.
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Make sure to sign and date the medical records, indicating your role as the healthcare provider responsible for completing the form.

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Healthcare providers: Doctors, nurses, and other medical professionals need 1402-2 medical records to properly document and track patients' health information, treatment plans, and progress over time.
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Government agencies: Government organizations, such as Medicare or Medicaid, may request 1402-2 medical records to determine eligibility for certain healthcare programs or conducting audits for compliance purposes.
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