"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."
Treatment. Examination. Minor Surgery.
Yes a premature death can occur if the dimensions of health are underdeveloped.
Soap?
Situation, objective, assessment, & plan for treatment, for the patient's chief complaint.
