All entries in the medical record must be legible. These entries include written progress notes, nursing notes, physical therapy, occupational therapy, speech therapy, consultations, and other notes that are handwritten in the patient's medical record to support the treatment provided during the visit or stay.

Question

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Legible entries in the medical record are crucial for ensuring accurate communication among healthcare providers, facilitating continuity of care, and supporting billing and legal documentation. Illegible handwriting can lead to errors in patient treatment and misunderstandings among care team members.

All Entries in the Medical Record Must Be Legible