Sample Medical Records documentation
Abbreviations and symbols in the patient record should adhere to the on-line abbreviation list. (DOH 115.33 (c) See Section 25 for specifics. ... Any additional secondary diagnoses, including complications and/or comorbities. ... medical records from the Emergency Care Unit will contain the following: a. Time and means of arrival (JCAHO IM 6.10 ... ................
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