What MUST be included in medical documentation?
Back in the day I was a medic in the US Army and during my service I had probably written a couple thousand SOAP (a style of medical documentation) notes. One thing that I have heard many people say is “a medical record is a legal document, if you don’t write it down, it didn’t happen”. I have done a lot of research regarding the above statement on line, the public library, and the local law library
Categories: Mortgage Tags: above-if-fact, doctors-orders, documentation notes, general - misc topics, healthcare worker, legal-document, medical documentation, medical-record, own accord, procedural skill, referenced, situation, skill set, states-the-same, the-referenced, thought-process, us army, write-it-down