"Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers. These features address traditional well-known requirements for documentation principles while supporting expansive new technologies. Use of these features without appropriate management and guidelines, however, may create information integrity concerns such as invalid auto-population of data fields and manufactured documentation aimed to enhance expected reimbursement. Processes must be in place to ensure the documentation for the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely."
<span>The release of breast milk that occurs when a mother hears a crying child is called the milk letdown reflex.</span>
Only state facts, not opinions, always date and time the documentation, document as soon as it happens, if it’s not documented then it did not happen
