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Progress note documentation demonstrates a Communication and Professionalism Competency.
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Complete and properly executed orders are of the utmost importance in ensuring adequate communication among team members and in ensuring patient safety.
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All patient interactions that are completed at the point of care and are properly dated and timed lead to less ambiguity later on.
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At times you may need to document your medical decision-making rationale to clarify treatment decisions to the health care team.
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Lack of proper documentation often leads to inquires regarding the quality of care delivered and possible deception.
- Our movement to electronic order entry and the true electronic medical record ensures that health care is as the Institute of Medicine (IOM) puts it:
- Timely
- Safe - legible, accurate, complete
- Effective
- Efficient
- Equitable
- Patient-Centered
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