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Competency 6. Maintain comprehensive, timely, and legible medical records, if applicable

      Medical documentation serves many purposes in our health care system,
      • Glondys B.
      Ensuring legibility of patient records (AHIMA Practice Brief).
      including the following:
      • Communication and clinical care planning among caregivers.
      • Providing a basis for assessing quality of care.
        • Opila D.
        The impact of feedback to medical housestaff on chart documentation and quality of care in the outpatient setting.
      • Legal recording for protection of patients, providers, and facilities.
      • Providing a clinical database for research and education.
        • Weed L.
        Medical records that guide and teach.
        • Mayefsky J.H.
        • Foye H.R.
        Use of a chart audit: teaching well child care to paediatric house officers.
      • Documentation for billing of the services provided.
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      References

        • Glondys B.
        Ensuring legibility of patient records (AHIMA Practice Brief).
        J Am Health Inform Manage Assn. 2003; 74 (64A–D)
        • Opila D.
        The impact of feedback to medical housestaff on chart documentation and quality of care in the outpatient setting.
        J Gen Intern Med. 1997; 12: 352-356
        • Weed L.
        Medical records that guide and teach.
        N Engl J Med. 1968; 278: 593-600
        • Mayefsky J.H.
        • Foye H.R.
        Use of a chart audit: teaching well child care to paediatric house officers.
        Acad Med. 2009; 27: 170-174
        • Moran M.
        • et al.
        Measuring medical residents' chart documentation practices.
        J Med Educ. 1988; 63: 859-865
        • Joint Commission on Accreditation of Healthcare Organizations
        Hospital Accreditation Standards.
        Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill2002
        • National Committee for Quality Assurance
        Guidelines for medical record review.
        in: Standards for the Accreditation of MCOs. National Committee for Quality Assurance, Washington, DC2001
        • Stange K.C.
        • Zyzanski S.J.
        • Smith T.F.
        • et al.
        How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits.
        Med Care. 1998; 36: 851-867
        • Ash J.
        • Berg M.
        • Colera E.
        Some unintended consequences of information technology in health care: the nature of patient care information system-related errors.
        J Am Med Inform Assn. 2004; 11: 104-112
        • Hartzband P.
        • Groopman J.
        Off the record: avoiding the pitfalls of going electronic.
        N Engl J Med. 2008; 358: 1656-1657
        • Thielke S.
        • Hammond K.
        • Helbig S.
        Copying and pasting of examinations within the electronic medical record.
        Int J Med Inform. 2007; 76: S122-S128
        • Dreyfus H.L.
        • Dreyfus S.E.
        Mind Over Machine.
        Free Press, New York, NY1988
        • Carraccio C.
        • Benson B.
        • Nixon J.
        • Derstine P.
        From the educational bench to the clinical bedside: translating the Dreyfus Developmental Model to the learning of clinical skills.
        Acad Med. 2008; 83: 761-767
        • Bereiter C.
        • Scardemalia M.
        Surpassing Ourselves: An Inquiry Into the Nature and Implications of Expertise.
        Open Court Publishing Company, Chicago, Ill1993
        • Pangaro L.
        A new vocabulary and other innovations for improving descriptive in-training evaluations.
        Acad Med. 1999; 74: 1151-1157