Journal Q&A (1/05)
Q: Is there a standard addressing who should document in medical records?
A: The answer to this question is left up to individual organizations. Most facilities create a policy that covers who can document in a patient’s medical record. This may also be covered in the medical staff bylaw....
You are trying to access a resource only available to AHIMA members. Join today to have full access to everything in the BoK, take advantage of all the benefits of AHIMA membership, and become part of a network of more than 103,000 health information management professionals strong.