RESUMO
1. Use of forced entry charts facilitates proper chart documentation and helps assure compliance with Medicare's chart documentation requirements. 2. Nurses and technicians are responsible for up to two-thirds of the required chart documentation in the patient's record. 3. Performance and documentation are not synonymous. There must be a meticulous written record of what was performed as well as negative and positive findings for both the history and the examination portions of the exam. Recording possible, probable, and rule/out diagnoses enhances the level of complexity of medical decision-making.
Assuntos
Documentação/normas , Prontuários Médicos/normas , Medicare , Indexação e Redação de Resumos , Controle de Formulários e Registros , Humanos , Anamnese/normas , Oftalmologia/normas , Exame Físico/normas , Mecanismo de Reembolso , Estados UnidosRESUMO
A technique utilizing a thin silicone sheet and a polyethylene tube to surgically repair symblepharon is described. A summary of cases treated by this technique is reviewed and other areas for further study are discussed.