Specific standards that guide documentation in a medical record are devised by:

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Accrediting agencies, such as The Joint Commission and the Centers for Medicare and Medicaid Services, establish and enforce specific standards for documentation in medical records. These standards ensure that the documentation is complete, accurate, and compliant with legal and regulatory requirements. The dietitian and clinical nutrition manager may contribute to the development of specific documentation standards, but they are not solely responsible for them. The physicians may provide input on documentation standards related to medical care, but they are not responsible for overall documentation standards. Accrediting agencies, such as The Joint Commission, develop and enforce standards for documentation in medical records to ensure the accuracy and completeness of patient information. The other options listed may contribute to medical record documentation, but they do not solely guide the specific standards.

Specific Standards That Guide Documentation in a Medical Record Are