SCAN
NCH
October 2013

Quality Notice

Your help to ensure inclusion of key documentation elements in the medical record is needed. "The Centers for Medicare and Medicaid Services (CMS)" and "The Joint Commission (TJC)" require the following in all handwritten and electronic documentation:

"All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures."