Documentation in the GI Lab

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This article is designed to aid the Gastrointestinal Assistant in documentation in an endoscopy unit. Presented is an overview of the basic reason for medical records using two different concepts of charting. The definition of objective versus subjective documentation is discussed, with objective documentation recommended and samples of both offered. Three different topics are presented, with the basic idea of how to avoid legal problems in documentation. A list of items to consider when charting is submitted and a conclusion on the purpose of documentation is stated.

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