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Electronic documentation tools offer many features that are designed to increase both the quality and the utility of clinical documentation, enhancing communication between all healthcare providers.

These features address traditional well-known requirements for documentation principles while supporting expansive new technologies.

This is a fraud on the tax authorities, a criminal offence and is likely to get the lawyer who prepared the document disciplined by his regulator and possibly also charged as a co-conspirator.

For obvious reasons, any request to backdate a document for these reasons should be flatly turned down.

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But Health Care for America Now (HCAN) hopes to change that.

Processes must be in place to ensure the documentation for the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely.OASIS data is collected at various points during an episode of care such as admission, recertification and discharge.If a patient is hospitalized during an episode of care, additional OASIS data is collected to note a transfer of the care to the hospital, and upon discharge back home, a resumption of care OASIS is completed with updated data and a chance to update the diagnosis, and consider therapy visits if they were not originally part of the plan of care.There are a number of existing rules and regulations on documentation principles and guidelines that primarily address documentation authorship principles, auditing, and forms development in a paper health record.New guidelines are being sought by the healthcare industry that ensure and preserve documentation integrity in an age of electronic exchange and changes in the legal evidentiary requirements for electronic business and health records.

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