Medical Assistant Prep / Unit 11 MAS 267 short lesson, about 20 seconds
The Record Is a Legal Document
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The idea
Everything written in the health record is part of a legal document.
In practice
It must be accurate and completed promptly, and it should never be altered, deleted or falsified; abbreviations should be avoided in legal documentation.
Where people slip
Write only what you saw, heard, measured or did, and sign it as yourself.
Your place on the trail
Every lesson rests on earlier ones and opens later ones. Tap any to jump.
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