“If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation,” the recommendation reads.
Here are the seven characteristics of high-quality clinical documentation providers should review when noting opioid abuse or dependency in patients, according to AHIMA.
1. Clear
2. Consistent
3. Complete
4. Reliable
5. Precise
6. Legible
7. Timely
To access the AHIMA guidelines, click here.
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