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Major sections of the history include=
past history, social history, chief complaint, present illness, and review of systems
A countersignature is a form of authentication by an individual in addition to the signature by the original author of an entry. It is mandated by=
Health care services rendered must be documented to prove that care was provided and that good medical care is supported by patient record documentation. Therefore, inadequate patient record documentation may indicate=
poor health care delivery
Which of the following is NOT an administrative application of an electronic health record system=
medication administration record documentation
A long-term care hospital (LTCH) is defined in the Medicare law as a hospital that has an average inpatient length of stay (LOS) that is=
greater than 25 days
Long-term care services that provide assistance with activities of daily living (ADL) are associated with=
Rubber stamp signatures can be accepted by facilities if allowed by state and federal law. When rubber stamp signatures are authorized for use in a facility, a provider whose signature the rubber stamp represents must sign a statement that=
he or she alone will use the stamp to authenticate documents
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