Clinical Documentation Matters

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Abnormal Test Results

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Physicians in the CAMP Method training study reported that their most significant documentation concern, prior to training, was their ability to clearly document the clinical significance of abnormal test results.  Since Joint Commission and Medicare both require documentation of the clinical significance of abnormal test results, training your physicians using examples of abnormal test results with several different suggestions for documenting the clinical significance of the test [depending, of course, on the individual patient]  is a key area for initial, follow-up or refresher training for your medical staff.

 


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