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Documentation Guidelines for Medical Providers
University of Rochester
posted on 10/03/2011
Quick reference pocket guide for proper documentation of common medical and surgical conditions.
Suggested Uses
This is a concise and effective medical provider education material on a pocket reference card for appropriate treatment and chart documentation. Proper documentation helps in coding and quality of care issues.
Advantages
This effective pocket card lists brief guidelines for common medical and surgical conditions. It is designed to help MD/PA/NP document medical terminology in their notes based on Center for Medicaid and Medicare Services coding rules. The guidelines are listed in simple form for easy and quick reference.
File Number: 6-2037
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This innovation currently is not available for online licensing. Please contact Zubair Mirza at University of Rochester for more information.
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