Consistent, current and complete documentation in the medical record is an essential component of quality patient care. The following 21 elements reflect a set of commonly accepted standards for medical record documentation. An organization may use these elements to develop standards for medical rec...ord documentation. NCQA considers 6 of the 21 elements as core components to medical record documentation. Core elements are indicated by an asterisk (*).
May 17,2022 MEDBOX Issue Brief no.21