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Medical Record Completion Guidelines

Medical Record Completion Guidelines

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ii). All surgery, including outpatient iii). Any procedure requiring anesthesia other than minimal anesthesia (local anesthesia) iv). Observation admissions b. Authentication (signature) The document must be signed AND dated by the author or if written/dictated by a resident must also be signed by the attending/supervising physician. c. Content i).

  Surgery, Minimal

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