Joint Commission/CMS Required items for transcription in medical record - LECHOLS Posted: Apr 22nd, 2016 - 8:04 am
Can anyone give me a link/website that can tell me the required items necessary for progress notes and H&P for an inpatient stay? I am fairly new and work in a small rural hospital. We have a physician that is "bucking" the process of not copying and pasting from old records. We set up a template for him to use, but he is not in agreement. Please help.
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