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Unformatted text preview: the patients medical record must be sufficiently complete to provide reasonable information to a subsequent health care practitioner. The daily records, at a minimum, must contain appropriate clinical documentation for each visit, including date, subjective complaints, objective findings that support the services rendered on that date, assessment of the patients status/progress, diagnostic impression, therapeutic intervention(s) provided during the visit, recommendations and instructions given to the patient, and follow-up recommendations....
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This note was uploaded on 08/25/2011 for the course HCR 210 taught by Professor Byrnes during the Spring '11 term at University of Phoenix.
- Spring '11