EMR & Documentation
Purpose
Section titled “Purpose”What belongs on this page
Section titled “What belongs on this page”See Also
Section titled “See Also”References
Section titled “References”Suggested structure
Section titled “Suggested structure”- Charting standard: what must be documented, and when
- Note templates and smart phrases
- MDM (medical decision making) elements that drive billing level
- Addendum and correction procedure
- Site-specific do-not-do list (copy-forward, cloned notes, etc.)