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The Medical Record

Documenting clinical encounters is a crucial part of patient care—describing your thoughts and plans, and communicating with others about your patients.  Your care of the patient is not complete until the medical record is complete.  Residents and Fellows must follow the Medical Staff Bylaws regarding medical records.  Detailed information from the Bylaws can be found on the PCMH intranet page, beginning on page 85 of the Bylaws Handbook.  A copy may also be obtained from the GME Office. In brief:

March 17, 2009

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