Medical records
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Identify 4 requirements for documenting each of the following:
a patient's pain assessment and treatment
medication administration
verbal telephone orders
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Solution Summary
This solution discusses the requirments for documenting different sections of medical records.
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Four requirements for a patient's pain assessment and treatment:
Medical documents need to include subjective complaints of pain by a patient as well as an obejctive treatment plan for the pain.
Any medical history citing a patient's previous experience with the same or similar pain should be noted in a patient's records.
Once treatment begins a patient's medical records need ...
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