Deal Or No Deal Template Page 20

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Electronic Medical Records
• Conflicts with ROS and patient history
and/or presenting problem
• Name/date of individual entering
information into electronic record
• Failure to document review of information
obtained by ancillary staff (PFSH/ROS)
• Electronic signature?
• Cloned records – OIG Work Plan 2012-
2013
• “Over-documentation” – not medically
necessary

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