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Health Information Management Technology — Second Edition — - page 12 / 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 (continued)

Health record entries should be documented at the time service is provided

Authors of all entries should be clearly identified

Only approved abbreviations and symbols should be used in the health record

All entries should be permanent

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