EVERY patient story has a beginning, middle and ending. The Medical Record needs to tell the patient's story consistently from first encounter through admission and discharge.
Copy & Paste is only effective if you UPDATE the text. "No acute changes overnight" is simply not descriptive enough, and the Physician Assesment should be constantly (daily) updated.
Real world case studies are (unfortunately) readily available for teaching in each lesson, illustrating what is not so good versus what would have been much better in the medical record.
The most common high-value diagnoses are readily familiar, and are illustrated with simple explanations of exactly what auditors are looking to see documented in the medical record.
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