Health Information Management

Comply with MM.04.01.01 documentation requirements

HIM-HIPAA Insider, March 15, 2011

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by Jean S. Clark, RHIA, CSHA

I promised in a previous “Standards of the month” column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
 
MM.04.01.01 affects documentation because the medical record is the source for orders, regardless of whether a hospital is computerized.
 
Note: To read more, view the March issue of Medical Records Briefing.



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