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Documentation

Horizontales
Charting by exception
Health care provider giving an order verbally
Level of care for patient
One of 5 guidelines for quality documentation
Quickly see patient trends
Purpose of medical record
Traditional method of documentation
Sets standards for documentation
Verticales
Problem, intervention, evaluation
Combination of hardware and software that protects private networks
Subjective, objective, assessment, plan
Allows health care providers to directly enter orders
Legal medical record
Controls patient documentation in long term care settings
Written account of pertinent patient data
Responsible for protecting records from all unauthorized readers