CLINICAL DOCUMENTATION AUDIT TOOL



Clinical Documentation Audit Tool

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Review and/or order of clinical lab tests Does documentation reveal that more than half of the time was counseling or coordinating care? 4. Time Tools to audit patient records against the record standards have been developed to support patient safety and quality of care, professional best practice and assist

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CRC В» Clinical Documentation Audit Tools

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    Guidelines for Medical Record and Clinical Documentation available documentation and records. Audit tools developed at a local level to monitor the standards of In these clinical areas, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool.

    Tools to audit patient records against the record standards have been developed to support patient safety and quality of care, professional best practice and assist Mental Health Toolkit time-saving documentation and referral tools, coding aids, Clinical Information Systems/Delivery System Redesign;

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