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Documentation: Electronic Health RecordsContact Hours: 2.0 (Two) Course Expires: 6/26/2020 First Published: 6/26/2014 Copyright 2016 by RN.com All Rights ReservedReproduction and distribution of these
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Professional documentation is safe and effective when it accurately records important information and follows legal and ethical guidelines.
Healthcare professionals such as doctors, nurses, and therapists are required to file professional documentation that is safe and effective.
To fill out professional documentation safely and effectively, one must ensure the information is accurate, complete, and compliant with regulations.
The purpose of safe and effective professional documentation is to provide a detailed record of patient care, treatment, and outcomes for future reference and legal purposes.
Professional documentation must include patient demographics, medical history, medications, treatment plans, progress notes, and any other relevant information related to patient care.
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