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This PRESENT lecture is brought to you
by the generous sponsorship of
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Medical Documentation
by Mark Beylin, DPM
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Year after year, chief residents pass to their junior residents the
documentation outlines to maintain good hospital records.
Much like the childhood game “phone tag”, the information gets obscured and
watered down as the years go by. In this lecture, Dr. Mark Beylin provides new residents accurate
documentation skills, which will serve them well during their hospital tenure.
Medical documentation is the primary communication tool amongst physicians and
other healthcare providers that are involved in the patient care. It is
also the
best protection when your judgment and decision making is questioned in a malpractice proceeding.
When medical cases get tossed into the legal arena, it it wasn't written down,
it didn't happen.
Dr. Beylin’s presentation reviews the pre and postoperative note, post operative
orders, progress notes, admission orders, history and physical, consultative
report and discharge summary. He shows you how to document properly.
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