For the first half of 2010, The Joint Commission lists medical record documentation as one of the top ten standards in noncompliance. Citing RC.01.01.01 (complete and accurate medical records) as the standard with the highest noncompliance, TJC suggests conducting concurrent chart audits to ensure compliance. Additionally, providers should check compliance with verbal order standard RC.01.03.07 and assessment/reassessment standard PC.01.02.03.
The Joint Commission "TJC" Looking at Medical Record Documentation
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