Health Information Management

Take ownership of patients’ background health risks

HIM Briefings, January 1, 2009

We all do a great job in documenting our patients’ history and physical exams. We all document a past medical history that shows all of the conditions that can adversely affect our inpatients. We all document the medications our patients take for the diseases we put into the past medical history. And we all address the nutritional, renal, respiratory, and cardiac status of every admission. Right? Well, maybe not so much. Or maybe we don’t do it in every case. Here’s what we may tell ourselves: We know the information, but why should we document it? After all, it’s in the office records. The clinic has all of the information, so why should we duplicate it? The patient was just in the hospital one week ago, so the information is already there.

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