Clinical Documentation Samples

Listed below are samples of clinical documentation from actual records.

How would you describe your verbal query process?

	We don't verbal query at all
	We verbal query, but document the reason for the query
	We verbal query, but do not document the reason for the query
	We verbal query, but do not have a consistent policy on whether or not the reason for query is documented
	Not sure of our stance on the verbal query

Clinical Documentation Matters