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Health Information Management Technology — Second Edition — - page 11 / 48

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©2006 All rights reserved.

Form and Content of the Health Record (continued)

Guidelines for complying with statutory and regulatory laws and accreditation standards:

Policies and procedures should comply with all laws and standards

Health records should be systematically organized

Only authorized persons should document in the health record

Policies should specify who can receive and transcribe verbal orders

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