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Debra o· 5 ull1van
.
GUIDE TO
THIRD EDITION
Acknowledgments
It is interesting to me how each edition of this book bring real-world knowledge and hands-on patient care
has its own uniqueness. I have worked at a different experience where I would only have been able to read
place during the writing of each edition, and I hope and write about what others do.
that has resulted in a deep layering of experience and There is a tremendous team of people at F. A. Davis
knowledge that makes each edition better. I certainly who have been part of this project. Even though he
feel like each job change has enhanced my professional retired before this edition was published, my dear friend
practice and has enriched me as a person. I have met Andy McPhee was the driving (cajoling? bullying?)
and worked with some extraordinary health-care force behind the third edition. I hope he is enjoying
providers, and I have had valuable contributions from his much-deserved retirement and getting to write
so many of them. what he wants, when he wants, if he wants. When
First, I would like to say thank you to my colleagues Andy approached me about a third edition, one of the
at Academic Urology and Urogynecology of Arizona. most anxiety-producing aspects of considering it was
I have had such encouragement and support from this who would be the developmental editor because I had
great group of people. I am grateful to have learned from less-than-wonderful experiences on the two previous
so many outstanding health-care providers throughout editions. I need not have worried at all, as I have had
my more than 27 years in medicine. I have benefitted the very good fortune to work with Stephanie Kelly,
from the expertise of Jamie Bair, NP (cardiology); developmental editor extraordinaire! Stephanie’s
Jennifer Nelson, PA-C (psychiatry); Steve Turner, knowledge of the process, her organizational skills,
RN (hospice); Dr. Richard Guthrie (palliative care); her sense of humor, and her hard work have made the
and several outstanding hospitalists who wished to journey so enjoyable, and she has my deepest gratitude.
remain nameless. I’m thankful for a group of dedicated I’m also grateful for the guidance of and contributions
Information Technology people who have helped me from Melissa Duffield, Senior Acquisitions Editor;
navigate electronic medical records and who’ve answered George Lang, Director of Content Development;
my questions with enthusiasm. Amelia Blevins, Developmental Editor for Digital
I must take this opportunity to acknowledge Products; Megan Suermann, Content Project Manager;
two incredible women who added so much to the Lori Bradshaw, Developmental Production Editor at
Document Library that we included in this edition S4Carlisle P ublishing; and Robert Butler, Production
of the book: Madison Palmer, MMS, PA-C, not only Manager. There’s probably not another publishing com-
contributed the prenatal records, but she also provided pany around that would have supported this project as
valuable assistance with content in the prenatal chapter. F. A. Davis has done, and I’m humbled and honored
Larissa J. Bech, MSN, RN, FNP-C contributed the they chose to champion this book.
pediatric records. Without their contributions, the
—Debbie Sullivan
prenatal and p ediatric visit notes would not exist. They
Copyright © 2019 by F. A. Davis Company. All rights reserved. vii
00_Sullivan_FM.indd 7 7/5/18 5:15 PM

Brief Contents
Part 1: Foundations of Documentation

Chapter 1 Medicolegal Principles of Documentation 1
Chapter 2 The Comprehensive History and Physical Examination 23
Chapter 3 SOAP Notes 45
Part II: Documentation Related to Outpatient Care

Chapter 4 Documenting Prenatal Care and Perinatal Events 79
Chapter 5 Pediatric Preventive Care Visits 93
Chapter 6 Adult Preventive Care Visits 125
Chapter 7 Older Adult Preventive Care Visits 153
Chapter 8 Outpatient Charting and Communication 173
Chapter 9 Prescription Writing and Electronic Prescribing 195
Part III: Documentation Related to Inpatient Care

Chapter 10 Admitting a Patient to the Hospital 217
Chapter 11 Documenting Inpatient Care 257
Chapter 12 Discharging Patients from the Hospital 285
Appendices
Appendix A Document Library 309
Appendix B A Guide to Sexual History Taking 373
Appendix C I SMP’s List of Error-Prone Abbreviations, Symbols,
and Dose Designations 375
Bibliography 377
Index 387
Copyright © 2019 by F. A. Davis Company. All rights reserved. ix

Contents
Part 1: Foundations of Documentation

Chapter 1 Medicolegal Principles of Documentation 1
Learning Outcomes 1
Introduction 1
Medical Considerations of Documentation 2
Legal Considerations of Documentation 2
Other Purposes of Documentation 3
General Principles of Documentation 3
Medical Coding and Billing 5
Evaluation and Management Services 5
International Classification of Diseases Coding 6
Electronic Medical Records 8
Benefits of Electronic Medical Records 8
Barriers to Electronic Medical Records 9
Interoperability 9
Meaningful Use 9
Health Insurance Portability and Accountability
Act (HIPAA) 10
Health Insurance Portability 10
Electronic Health-Care Transactions 10
The Privacy Rule 10
Security Rule 13
Summary of the Act 14
Summary 14
Worksheets 15
Copyright © 2019 by F. A. Davis Company. All rights reserved. xi

xii | Contents
Chapter 2 The Comprehensive History and Physical Examination 23

Learning Outcomes 23
Introduction 23
Components of a Comprehensive History and Physical
Examination 23
History 24
Physical Examination 29
Laboratory and Diagnostic Studies 32
Problem List, Assessment, and Differential Diagnosis 32
Plan of Care 32
Sample Comprehensive History and Physical Examination 32
Summary 32
Worksheets 37
Chapter 3 SOAP Notes 45
Introduction 45
Subjective 45
Analyzing Documentation 47
Objective 48
Formats for Documenting Objective Information 49
Documenting Diagnostic Test Results 50
Interventions Done During the Visit 50
Assessment 52
Differential Diagnosis 53
Plan 54
Laboratory and Diagnostic Tests 54
Consults 54
Therapeutic Modalities 55
Health Promotion and Disease Prevention 55
Patient Education 55
Follow-Up Instructions 56
Summary 58
Worksheets 59
Copyright © 2019 by F. A. Davis Company. All rights reserved.

Contents | xiii
Part II: Documentation Related to Outpatient Care

Chapter 4 Documenting Prenatal Care and Perinatal Events 79
Introduction 79
Documentation of Prenatal Care 80
Demographic Information 80
Maternal History 80
Laboratory Data and Diagnostic Tests 82
Health Promotion and Disease Prevention 83
Documentation of Perinatal and Postpartum Care 83
Delivery Note 83
Postpartum Note 86
Newborn Physical Examination 87
Summary 87
Worksheets 89
Chapter 5 Pediatric Preventive Care Visits 93
Introduction 93
Components of Pediatric Preventive Care Visits 94
Growth Screening 94
Developmental Screening 98
Laboratory Screening Tests 99
Assessing Vaccination Status 100
Anticipatory Guidance 100
Risk Factor Identification 102
Age-Specific Physical Examinations 106
Pediatric Sports Preparticipation Physical Examination 106
Summary 109
Worksheets 111
Chapter 6 Adult Preventive Care Visits 125
Introduction 125

xiv | Contents
Documenting Preventive Care 126

Risk Factor Identification Based on Personal History 126
Risk Factor Identification Based on Family History 135
Risk Factor Identification Based on Screening Tests 135
Gender-Specific Screening 136
Health Education and Counseling 139
Assessing Vaccination Status 139
Summary 139
Worksheets 141
Chapter 7 Older Adult Preventive Care Visits 153
Introduction 153
Assessing Older Adult Risk Factors Through
History Taking 153
Medication Use 153
Functional Impairment 156
Nutrition 156
Sensory Deficit Screening 159
Mental Health Screening 160
Geriatric Syndromes 160
Assessing Older Adult Risk Factors Through
Sensory Examinations 161
Balance and Mobility Assessment 162
Cognitive Assessment 162
Additional Screening 162
Pre-operative Evaluation of Older Adults 162
Anticipating Future Needs 165
Advance Directives 165
Hospice and Palliative Care 166
Summary 166
Worksheets 167

Contents | xv
Chapter 8 Outpatient Charting and Communication 173

Introduction 173
Components of the Medical Record 173
Problem List 173
Medication List 176
Flow Sheets 179
Demographic and Billing Information 179
Results of Laboratory Studies and Other Diagnostic Tests 179
Noncompliance With Medical Treatment 179
Communication With Other Providers 182
Prior Medical Records 183
Documenting Communications With Patients 183
Telephone Communication 183
Electronic Mail 185
Patient Portal 187
Social Media 187
Benefits of Social Media 187
Concerns About Social Media 188
Provisions for Using Social Media 188
Summary 188
Worksheets 189
Chapter 9 Prescription Writing and Electronic Prescribing 195
Introduction 195
Federal and State Regulations and Prescribing Authority 196
Safeguards for Prescribers 197
Controlled and Noncontrolled Substances 199
Elements of a Prescription 199
Writing Prescriptions for Noncontrolled Medications 199
Prescriber Identification 199
Patient Identification 199

xvi | Contents
Inscription 200
Subscription 200
Signa or sig 200
Indication 200
Refill Information 200
Generic Substitution 201
Warnings 201
Container Information 201
Signature 201
Writing Prescriptions for Controlled Medications 201
Common Errors in Prescription Writing 202
Electronic Prescribing 203
Federal Initiatives for Electronic Prescribing 204
Qualified Electronic Prescribing 204
Benefits of E-Prescribing 205
Barriers to E-Prescribing 206
Summary 206
Worksheets 207
Part III: Documentation Related to Inpatient Care

Chapter 10 Admitting a Patient to the Hospital 217
Introduction 217
Admission History
and Physical Examination 218
Medical Admission History
and Physical Examination 218
Surgical Admission History and Physical Examination 221
Sample H&P 223
Admission Orders 223
Admit 227
Diagnosis 227
Condition 227
Activity 227

Contents | xvii
Vital Signs 227

Allergies 228
Diet 228
Interventions 228
Medications 228
Procedures 229
Laboratory and Other Diagnostic Studies 229
Special Instructions 229
Perioperative Orders 229
Admit 230
Diagnosis 230
Condition 230
Activity 230
Vital Signs 230
Allergies 230
Diet 230
Interventions 232
Medications 232
Procedures 233
Laboratory and Other Diagnostic Studies 233
Special Instructions 234
Computerized Physician Order Entry 234
Benefits of CPOE 235
Challenges and Barriers to CPOE 235
Admit Notes 237
Summary 238
Worksheets 239
Chapter 11 Documenting Inpatient Care 257

Introduction 257
Daily Progress Note 257
Content of a Daily Progress Note 257
Daily Orders 260

xviii | Contents
Consult Note 266

Full Operative Report and Operative Note 271
Other Types of Documents 272
Procedure Note 272
Summary 274
Worksheets 275
Chapter 12 Discharging Patients from the Hospital 285
Introduction 285
Discharge Orders 285
Disposition 286
Activity Level 286
Diet 286
Medication Reconciliation 286
Follow-Up Care and Notification Instructions 287
Discharge Summary 288
Dates of Admission and Discharge 288
Admitting and Discharge Diagnosis
(or Diagnoses) 288
Attending Physician, Primary Provider, and Consulting
Physician 289
Procedures 289
Brief History, Pertinent Physical Examination Findings,
and Pertinent Laboratory Values 289
Hospital Course 290
Condition at Discharge 291
Disposition, Discharge Medications, Discharge Instructions,
and Follow-Up Instructions 291
Patient Leaving Before Discharge 291
AMA 291
Elopement 293
Summary 294
Worksheets 295

Contents | xix
Appendices
Appendix A Document Library 309
Appendix B A Guide to Sexual History Taking 373
Appendix C I SMP’s List of Error-Prone Abbreviations, Symbols,
and Dose Designations 375
Bibliography 377
Index 387

Introduction
It’s no secret that medicine is constantly changing and chapters and to provide much more detail about the
evolving, but I guess I didn’t realize that there have been content. New content includes Chapter 4, Documenting
so many changes and evolutions in documentation until Prenatal Care and Perinatal Events, and Chapter 7,
I started working on the third edition. Since the second Older Adult Preventive Care Visits. Some chapters were
edition was published in 2011, there have been signif- relocated within the text to present a more chronological
icant changes in coding, billing, reimbursable services, sequence. Every chapter was revised; some revisions were
federal requirements for documentation, platforms for fairly minor, whereas others were extensive. Medicolegal
documentation, and so on. And, thanks to the feedback Alerts are included in each chapter to help highlight
from users of this text and thoughtful reviews by edu- important concepts. New to this edition are images of
cators and practitioners, the “wish list” of content for electronic medical record (EMR) entries, or screen shots.
this text has changed as well. So, here you have it, the There are multiple EMR systems available, so what is
third—and by far, the best—edition. One thing that presented may look different from what you’ve seen
has not changed is the basic principle of the book—this before, but I think it is helpful to see sample entries
is an instructional work on documentation and is not from different systems.
meant to be an instructional work on the practice of Sometimes Appendices don’t get a lot of attention,
medicine. Documentation and the practice of medicine but I hope you’ll check out Appendix A, the Document
are interrelated, and it is sometimes a challenge to keep Library. In the library, you’ll find documents that per-
them separate. However, they are two distinctly differ- tain to a particular patient grouped together in a way
ent practices. As an educator, I teach. As a Physician that captures the patient’s care chronologically. This
Assistant, I practice medicine. As an author, sometimes provides a different perspective than seeing them as
I want to do both, but that has never been the goal. “stand-alone” documents in multiple chapters.
The goal is to provide a solid foundation of principles Many educators mentioned that they would like the
of documentation that will preserve important aspects worksheet answers moved out of the book so that they
of the health-care provider–patient encounter while could be used more effectively as an educational tool,
meeting the requirements for reimbursement and other so this was done. You can find them in the Instructor’s
regulations. There are many examples of documenta- Guide, at DavisPlus on the F.A. Davis website, which
tion of various encounters throughout this book, and will allow you to provide them to the students as you
each is just one example of how an encounter may be see fit—you can simply provide the answers so students
documented. There is not just one way to document can check their own work, or you can use the worksheets
any encounter but many different ways; and different as graded assignments.
doesn’t mean “good” and “bad”—just different. I’m of Whether you are a student, a novice practitioner, or an
the opinion that the more examples you see, the more experienced provider, I hope this book will be a valuable
you will learn and the more prepared you will be when resource in your journey of professional development.
it comes time for you to document your way.
—Debbie Sullivan
Revisions started with the Table of Contents, which
Phoenix, Arizona
has been expanded to highlight sections within the
Copyright © 2019 by F. A. Davis Company. All rights reserved. xxi

PART I Foundations of Documentation
Chapter 1
Medicolegal Principles
of Documentation
LEARNING OUTCOMES
• Discuss medical and legal considerations of documentation.
• Identify groups of people who may access medical records.
• Identify general principles of documentation.
• Discuss medical coding and billing.
• Define the terms electronic medical records, meaningful use, and interoperability.
• Identify benefits of using electronic medical records.
• Identify challenges and barriers to using electronic medical records.
• Identify components of the Health Insurance Portability and Accountability Act.
• Discuss principles of confidentiality.
documentation and puts a greater burden on providers

Introduction to capture their thoughts and actions for others to read
and interpret years after an episode of care took place.
You might be asking, “Why a book on documentation?”
Dr. Mitchell Cohen wrote about this evolution of
Documentation is one of the most important skills a
documentation in an article that appeared in Family
health-care provider can learn. You might feel tempted
Practice Management.* Dr. Cohen explains:
to focus considerably more time and energy on learning
other skills, such as physical examination, suturing, or From time to time I’ll stumble upon an old chart in my
pharmacotherapeutics. These are essential skills, but office that goes back 40 years. My predecessors charted
documentation is likewise extremely important. State office visits on sheets of lined manila card stock, which
licensure laws and regulations, accrediting bodies, would suffice for at least 15 to 20 visits. Clearly, these
professional organizations, and federal reimbursement charts were only intended for the physicians as a way to
programs all require that health-care providers maintain refresh their memory of what happened from one visit to
a record for each of their patients. the next. For example, the documentation for one visit
Documentation used to be mostly a memory aid read simply, “1/20/67: pharyngitis >> penicillin.” These
for the provider—a quick note of his or her thoughts days chart notes are primarily not for the physician or
about a patient’s presentation, a likely diagnosis, maybe patient, but for all the others who aren’t in the exam
a few words about the treatment plan. Over the past room and yet feel they have a stake in what takes place
few decades, however, documentation has become a in this once confidential arena. To satisfy coders and
more complex task due to changes in medicine and insurers, my documentation for a 99213 sore throat
with patients themselves. Increased complexity in the visit must contain one to three elements of the history
medical field is evident by the ever-increasing number of present illness, a pertinent review of systems, six to
of medications and treatment modalities available to 11 elements of the physical exam, and low-complexity
health-care providers. In addition, patients live longer medical decision-making. My malpractice carrier and
with a greater number of comorbid conditions, adding my future defense attorney would also like me to explain
to the complexity of caring for them and requiring that my clinical rationale for why the patient has strep throat
complexity in the medical records. The fact that our so- and not a retropharyngeal abscess or meningitis. A table
ciety is so litigious certainly adds more weight to clinical with a McIsaac score calculating the likelihood that this
1
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2 | Guide to Clinical Documentation
patient does indeed have strep throat might be nice as record also serves other purposes and has audiences
well. If I prescribe a weak narcotic for a really nasty other than the patient and the health-care provider; it is
case of strep, the state medical board would be pleased both a medical and a legal document. The medical record
if I addressed what other medications have been tried establishes your credibility as a health-care provider. It
and whether the patient has any history of addiction. is important to remember that you are creating a record
I’ll also need to document that I explained the proper that other professionals will read; therefore, you should
use of the medications and the need for follow up if the use professional language and include appropriate
patient doesn’t get better. When I’m finally done with content. Other readers will assume, rightly or wrongly,
my note, it looks like this: that you practice medicine in much the same way that
you document. If your documentation is sloppy, full
CC: sore throat x 2d of errors, or incomplete, others will assume that is the
HPI: 17 y/o F with 2d h/o sore throat. Has an asso- way you practice. Conversely, thorough, legible, and
ciated headache and fever to 1018F. No significant complete documentation will infer that you provide
cough. Patient has noticed some swollen lumps in care in the same way, thus establishing your credibility.
neck. Having significant pain despite use of Tylenol, Some excellent providers simply do not have good doc-
ibuprofen and salt water gargles. umentation skills. However, this is the exception rather
Social Hx: no h/o substance abuse or addiction. than the rule. It is very difficult to persuade those who
ROS: denies neck stiffness or back pain, no rash. No read sloppy documentation that the person who wrote
difficulty speaking. that way can, and did, provide good care.
PE: VS: AF, VSS Up-to-date and complete documentation is an essential
Gen: alert, pleasant female in NAD component of quality patient care. The medical record
HEENT: NC/AT, PERRLA, EOMI, TM clear b/l, is the primary means of communication between mem-
OP notable for tonsillar enlargement with exudates. bers of the health-care team and facilitates continuity
No asymmetry or uvular deviation present. of care and communication among the professionals
Neck: + tender anterior cervical adenopathy, no nuchal involved in a patient’s care. Although many patients
rigidity or meningismus. will have a primary care provider who provides most of
CV: RRR S1/S2 without murmurs. their care, patients also may see specialists for specific
C/L: CTAB problems. Medical records are the vehicle for com-
Abd: soft, nondistended, nontender, no hepatosplenomegaly. munication among members of the health-care team,
McIsaac’s score = 4; Rapid strep + and the medical record is the common storehouse for
A: streptococcal pharyngitis all information about the patient’s care and condition
P: 1) Pen VK 500 mg po TID x 10 days. Discussed regardless of who is providing that care.
risks of medication including allergic reaction and
complications of not taking full course of antibiotics
including rheumatic fever and valvular heart disease.
2) hydrocodone elixir q HS to help relieve pain par- Legal Considerations
ticularly when trying to rest. Has already tried
acetaminophen and NSAID and will continue salt
of Documentation
water gargles. Follow up if no improvement in one As mentioned previously, all medical records are legal
week. Have discussed other potential diagnoses and documents and are important for both the health-
reviewed warning signs of retropharyngeal abscess care provider and the patient, regardless of where the
and meningitis. Patient agrees and understands plan. patient care takes place. The most important legal
functions of medical records are to provide evidence
Like I said, “pharyngitis >> penicillin.” that appropriate care was given and to document
(*Used with permission of the American Academy of the patient’s response to that care. An often-quoted
Family Physicians) principle of documentation, which every health-care
provider has probably heard, is that if it is not doc-
umented, it was not done. This is a fallacy because it
Medical Considerations is impossible to capture with documentation every
nuance of a patient–provider encounter, and it is im-
of Documentation possible to create a perfect record of every encounter.
However, the principle behind the quote is important
As illustrated in the example, the medical record serves in a legal context; there is a considerable time lapse
to document the details of the patient’s complaint and between when events occur (and are documented)
the medical evaluation and treatment. The medical and when litigation occurs. It may be anywhere from

Chapter 1 Medicolegal Principles of Documentation | 3
2 to 7 years from the occurrence of an event until you Clear and concise documentation is required to receive
are called to give a sworn account of the event. The accurate and timely payment for furnished services.
medical record is usually the only detailed record of Peer-review organizations might read the record to
what actually occurred, and only what is written is determine whether the care reflected in your doc-
considered to have occurred. You will not remember umentation is consistent with the standard of care.
the details of an event that happened 6 years ago; your Researchers often obtain access to medical records for
only memory aid will be the medical record. As a legal purposes of conducting scientific studies. Although it
document, the medical record that you authored will be is important to remember that these audiences may
made available to plaintiff attorneys, defense attorneys, have access to your records, you should keep in mind
malpractice carriers, jurors, judges, and, most likely, that the primary audience of the medical records will
the patient. You should keep this in mind at all times be medical professionals involved in direct patient care.
when documenting. Throughout this book, you will analyze examples of
The record should be objective. Personal, subjective documentation. You may also complete the worksheets,
opinions regarding the patient, the patient’s family, or which will help you apply the information as you read
other providers do not belong in the medical record. It it. The purpose of this book is to teach documentation
is human nature to make value judgments about others, skills and critical analysis of medical records, not to
but it is asking for trouble to note in a record those instruct on the practice of medicine or to teach medical
irrelevant judgments about the patient. Document facts; decision-making. The content of a medical record—or
not opinions. All providers should strive for accuracy learning what to document—varies greatly, depending
in documentation. Correcting a medical record is not on the patient’s presenting problem or condition. The
only encouraged, but it is necessary in order to avoid principles of how to document and why documentation
potentially harmful mistakes or misrepresentations. is important do not vary as much and, thus, are the
Altering a record should never be done. Alteration con- focus throughout this book.
notes an improper change, concealment, or omission of
portions of records that were written inappropriately.
Correction implies the act of making something right. General Principles
Record alterations have rendered many defensible cases
indefensible. Most jurors will suspect that a provider of Documentation
who alters records has done so to cover up a mistake.
The Centers for Medicare and Medicaid Services (CMS)
The opposing attorney will argue that alteration shows
is one agency of the U.S. Department of Health and
consciousness of guilt. Alterations in medical records
Human Services (HHS). As one of the nation’s largest
may give rise to a claim for punitive damages against a
payers for health-care services, CMS has established
provider. Intentionally altering or destroying a patient’s
specific guidelines for documentation that are referenced
chart is considered unprofessional conduct. Most states
several times throughout this book. There are two sets of
will consider a practitioner who alters or destroys a
documentation guidelines currently in use: the 1995 and
patient’s chart to have violated the applicable licensing
the 1997 guidelines. CMS published an evaluation and
statute and will sanction or suspend the practitioner’s
management guide in 2015; however, it was offered as a
license to practice medicine.
reference tool and did not replace the content found in
the 1995 and 1997 guidelines. There are minor differences
Other Purposes between the two guidelines, and it is recommended
that health-care providers refer to the guidelines to
of Documentation identify those differences. Additional information may
be found at www.cms.gov/Outreach-and-Education/
Reviewers from various organizations can obtain Medicare-Learning-Network-MLN/MLNProducts/
access to a medical record for a variety of purposes. Downloads/eval-mgmt-serv-guide-ICN006764.pdf.
Health-care payers require reasonable documentation Both sets of guidelines recognize the following
for a number of reasons: general principles of documentation:
• To ensure that a service is consistent with the pa- 1. The medical record should be complete and
tient’s insurance coverage legible.
• To validate the site of service, medical necessity, 2. The documentation of each patient encounter
and appropriateness of the diagnostic and/or should include the following:
therapeutic services provided • Reason for the encounter and relevant history,
• To confirm that services furnished were accurately physical examination findings, and diagnostic
reported test results

• Assessment, clinical impression, or diagnosis systems create a “digital footprint” every time a record
• Plan for care is accessed. This digital footprint includes the date and
• Date and legible identity of the health-care time and the identity (typically name and title and/or
provider role) of the person accessing the record. The system
3. If not documented, the rationale for ordering also will indicate the time and date of any updates or
diagnostic and other ancillary services should be changes made to the record. You should never document
easily inferred. in a patient’s record in advance of seeing the patient. In
4. Past and present diagnoses should be accessible addition, you can correct or amend a patient’s medical
to the treating and consulting providers. record, but you should never alter it. At times, it will
5. Appropriate health risk factors should be be necessary to make corrections to a record. When
identified. making a correction in a paper record, you should draw
6. The patient’s progress, response to and changes a single line through the text that is erroneous, initial
in treatment, and revision of diagnoses should be and date the entry, and label it as an error. If there is
documented. room, you may enter the correct text in the same area
7. The diagnosis and treatment codes reported on of the note. You should not write in the margins of a
the health insurance claim form or billing state- page; if there is no room to enter the correct text, use
ment should be supported by the documentation an addendum to record the information. You should
in the medical records. (More discussion of bill- never obliterate an original note, nor should you use
ing and coding is included later in this chapter.) correction fluid or tape. In the EMR, once a document
is submitted, it is still possible to modify or correct
There are other generally accepted principles of the record. If an entire entry is incorrect (for exam-
documentation, such as that each entry should include ple, charting on the wrong patient), there is a process
the date and time the record was created and should to identify the entry as an erroneous document. The
identify the person creating the record. In settings in process will vary with different EMR systems, and
which care is provided around the clock, military time institutions will have their own policy for identifying
is often used to avoid confusion between a.m. and p.m. erroneous entries.
One o’clock in the afternoon is 1300, 10:30 at night is Based on your reading, complete the application
2230, and so forth. Electronic medical record (EMR) exercise that follows.
Application Exercise 1.1

After seeing patient E. H. and documenting the encounter, you realize that you previously entered medications
and allergies for another patient in E. H.’s chart. Correct the record to show the correct medications as follows:
Zocor 20 mg daily, metformin 500 mg daily, Synthroid 0.125 mg daily.
PMH: E. H. has a history of type 2 diabetes (diagnosed at age 41), hypothyroidism (diagnosed at age 37), and
hyperlipidemia (diagnosed at age 39). Surgical history includes tonsillectomy as a child and cholecystectomy at
age 42. Medications include Lasix 20 mg daily, Diovan 80 mg daily, warfarin 5 mg daily, and vitamin D, 2 capsules
daily. Allergic to sulfa drugs. Family history is positive for diabetes in mother and maternal grandmother and
heart disease in paternal grandfather.
Application Exercise 1.1 Answer
PMH: E. H. has a history of type 2 diabetes (diagnosed at age 41); hypothyroidism (diagnosed at age 37), and hyperlipidemia
(diagnosed at age 39). Surgical history includes tonsillectomy as a child and cholecystectomy at age 42. Medications include
HUURUGV=RFRUPJGDLO\PHWIRUPLQPJGDLO\6\QWKURLGPJGDLO\
Lasix 20 mg daily, Diovan 80 mg daily, Warfarin 5 mg daily, and vitamin D, 2 capsules daily. Allergic to sulfa drugs.
Family history is positive for diabetes in mother and maternal grandmother, and heart disease in paternal grandfather.
If using a ruled sheet such as an order sheet or not read” or “dictated but not reviewed” because doing
progress note, be sure that there are no blank lines. so will call attention to the fact that you did not verify
If a record is dictated and then transcribed, read the the content of the record.
transcription before signing it, correcting any errors in When entering the medical field, you must learn the
the process. You should not stamp a record “signed but language in order to function. Part of learning this language

is to learn the meaning of the abbreviations, acronyms, with a hyphen. The third category of CPT codes cor-
and symbols in use; therefore, they are incorporated in responds to emerging medical technology. There are
this text. Abbreviations are a convenience, a time saver, approximately 7,800 CPT codes, and the codes are
a space saver, and a way of avoiding the possibility of updated annually.
misspelled words. Incorporating abbreviations is not
an endorsement of their legitimacy, but it is intended Evaluation and Management Services
to assist individuals in reading and understanding When a patient presents for care, you as the health-care
medically related documents. Sometimes abbreviations provider evaluate the patient and then proceed to manage
are not understood. They can be misread or interpreted the presenting complaint. That encounter between you
incorrectly. For example, the abbreviation “CP” could and the patient may vary from brief to comprehen-
mean “chest pain” or “cerebral palsy.” Of course, the rest sive depending on the patient’s chief complaint. For
of the entry should make clear the term for which the example, the time required for evaluation of a child
abbreviation is being used. There are variations in how who presents with a sore throat is typically brief, and
an abbreviation can be expressed. “Anterior-posterior” the management options are fairly straightforward.
has been written as AP, A.P., A/P. Abbreviations may Conversely, more time is required for evaluating an
appear as all uppercase or all lowercase, and they may older adult who has several chronic conditions and a
or may not have periods after each letter (for example, new complaint of chest pain, and the evaluation and
PRN, prn, P.R.N., meaning “as needed”). Many inherent management process is more complex.
problems associated with abbreviations contribute to CPT codes assigned for E/M services are deter-
or cause errors. Health-care organizations should for- mined by several factors. One factor is whether the
mulate a “Do Not Use” list of dangerous abbreviations, patient is new, established, or seen for consultation
and you as the health-care provider are responsible for services, and another is the setting where care is
complying with your institution’s policies regarding provided. Complexity of service is another factor
use of abbreviations. and is determined by three key elements: history
(including history of present illness [HPI]; review of
systems [ROS]; and past medical, family, and social
Medical Coding and Billing history [PMFSH], which are explored in Chapter 2),
physical examination, and medical decision-making.
Concise documentation of the medical encounter is The complexity considers the presenting complaint,
critical to providing patients with quality care and to co-existing medical problems, amount of data to be
ensuring accurate and timely reimbursement. Medi- reviewed (i.e., tests and old records), amount of time
cal records are subject to review by payers to validate that you spend with the patient, number of diagnoses
that the services provided were medically necessary and treatment options, and risk for significant com-
and were consistent with the individual’s insurance plications. Table 1-1 summarizes the requirements for
coverage. Standard codes are assigned to reflect the each level of E/M based on history, physical exam-
health-care diagnosis, procedures, and medical ser- ination, and complexity of medical decision-making.
vices provided and to create a uniform vocabulary In the case where counseling and/or coordination
for claims processing, medical care review, medical of care constitutes more than 50% of the encounter,
education, and research. Two important code sets are time is considered the key or controlling factor to
the Current Procedure Terminology (CPT) and the qualify for a particular level of E/M services. This
International Classification of Diseases (ICD) codes. includes time spent with parties who have assumed
CPT codes are used to document many of the med- responsibility for the care of or decision-making for
ical procedures performed in a physician’s office. This the patient. If you elect to report the level of service
code set is published and maintained by the American based on counseling and/or coordination of care, then
Medical Association (AMA). CPT codes are five-digit you would document the total length of time of the
numeric codes that are divided into three categories. encounter, and you should describe in the record the
The first category is used most often, and it is divided counseling and/or activities performed to coordinate
into six ranges that correspond to six major medical care. Counseling includes discussion of diagnostic
fields: Evaluation and Management (E/M; discussed results, impressions, and/or recommended diagnostic
in more detail next), Anesthesia, Surgery, Radiology, studies; prognosis; risks and benefits of management
Pathology and Laboratory, and Medicine. The second options; instructions for management and/or follow-up;
category of CPT codes corresponds to performance importance of compliance with chosen management
measurement and, in some cases, laboratory or radiology (treatment) options; risk factor reduction; and patient
test results. Typically, these five-digit, alphanumeric and family education. An example of documentation
codes are added to the end of a Category I CPT code of time spent with a patient is shown in Example 1.1.

Table 1-1 Levels of Evaluation and Management Based on History, Physical Examination,
and Complexity of Medical Decision-Making
Level of History HPI ROS PMFSH
Problem focused Brief (one to three elements) None None
Expanded problem Brief (one to three elements) One system None
focused
Detailed Extended (four or more Two to nine systems One pertinent PMFSH (one
elements) from any of the three)
Comprehensive Extended (four or more 10 or more systems Complete PMFSH
elements)
Type of Physical
Examination Examination Description 1995 Guidelines 1997 Guidelines
Problem focused Limited to affected body area or One body area or organ One to five bulleted items
organ system system
Expanded problem Affected body area/organ system Two to seven body areas Six to 11 bulleted items
focused and other symptomatic or or organ systems
related organ system(s)
Detailed Affected body area/organ system Two to seven body areas 12 to 17 bulleted items for
and other symptomatic or or organ systems two or more systems
related organ system(s)
Comprehensive General multisystem Greater than eight body 18 or more for nine or
areas or organ systems more systems
Amount of Data Risk for Complications,
Medical Number of Treatment (Diagnostic Studies, Morbidity and/or
Decision-Making Options Prior Records) Mortality
Straightforward One or less One or less Minimal
Low Two Two Low
Moderate Three Three Moderate
High Four or more Four or more High
EXAMPLE 1.1 mortality and morbidity statistics. These standardized

J.K. is a 62-year-old established patient who comes
codes are used by national and international agencies
in to discuss use of cholesterol lowering medication.
and organizations to forecast health-care needs, evaluate
More than half of the time of the encounter was spent
facilities and services, review costs, and conduct studies
providing patient education and counseling, and you
of trends in diseases over the years. ICD was established
document the following:
by the World Health Organization in the late 1940s
and has been updated several times in the years since
A total of 15 minutes was spent face-to-face with the patient its inception. The number following “ICD” represents
during this encounter, and over half of that time was spent which revision of the code is in use; therefore, “ICD-10”
on counseling. We discussed in-depth the results of his most represents the 10th revision. ICD-10 has more than
recent labs, specifically high cholesterol and triglyceride levels, 155,000 codes and has the capacity to accommodate
his risk factors for coronar y disease (smoking, high cholesterol, new diagnoses and procedures, expand descriptions of
and family histor y), and the importance of primar y prevention some diagnoses, and allow more detailed tracking of
of coronar y disease with aggressive treatment of high choles- mortality and morbidity. The ICD codes are updated
terol. I also educated the patient about lifestyle modifications every October; therefore, health-care providers and
that may improve blood pressure and help lower cholesterol. coding and billing personnel must ensure that they are
using the most up-to-date code set.
An ICD code is assigned to identify the diagnosis,
International Classification of Diseases symptom, condition, problem, complaint, or other reason
Coding for the encounter. When assigning a diagnosis and code,
Whereas CPT codes indicate what services and procedures you should be as descriptive as the data allow and use
were provided, the ICD codes explain the reason for the medical terminology rather than lay terminology. For
services. The ICD code is a diagnostic coding system example, instead of documenting “runny nose,” you should
that classifies diseases and injuries and is used to track use “rhinorrhea.” This does not work in every situation;

there is no medical term for “chest pain” when used as The primary code would be abdominal pain
a diagnosis, unless you know what is causing the chest (R10.10 if upper abdominal pain or R10.30 if
pain. When claims are submitted for payment, both CPT lower abdominal pain).
and ICD codes are provided, and your documentation 4. Secondary codes are listed after the primary code
must support the level of service billed. CPT codes work and expand on the primary code or define the
in tandem with ICD codes to create a full picture of need for a higher level of service.
the medical process for the payer; “this patient arrived • In the previous example, if the patient with
with these symptoms (as represented by ICD codes) abdominal pain has bloody vomitus, then
and these procedures were performed” (represented by hematemesis (K.92) would be coded as a
CPT codes). Downcoding is the process by which an secondary diagnosis.
insurance company reduces the value of a procedure or 5. Code a chronic condition as often as applicable
encounter and resulting reimbursement because either to the patient’s condition.
(1) there is a mismatch of CPT code and description, • Using example 3, the patient’s history of de-
or (2) the ICD code does not justify the procedure or pression may not be pertinent to the complaint
level of service. The quality and accuracy of the medical of abdominal pain, so it would not be coded;
record are vital to the reimbursement process, which, in however, diabetes would be coded.
turn, is vital to the delivery of health care. 6. Code co-existing conditions that may have an
influence on the outcome.
MEDICOLEGAL ALERT ! • In example 3, depression is a co-existing
condition that may alter a patient’s percep-
Although getting paid is a very important issue for tion of abdominal pain. The patient may take
health-care providers, you should never code for re- antidepressant medication, which could cause
imbursement purposes only. This can be construed as the pain. Coding both the chronic condition
fraud. Remember, your documentation must support the (diabetes) and co-existing condition (depres-
level of service and the diagnoses reported. sion) demonstrates the higher level of care
needed to manage the patient.
7. Do not use “rule out . . .” as a diagnosis.
Good documentation is absolutely essential to support • There is no code for this. Instead, use a
the level of E/M services and facilitate assignment of diagnosis, symptom, condition, or problem.
correct CPT and ICD codes. Here are some key con- You may use “rule out” when documenting the
cepts showing the interrelatedness of documentation assessment to guide you in your plan of care,
and codes and an illustrative example of each concept: although it is not necessary.
8. Signs and symptoms that are routinely associ-
1. Any tests ordered must correlate with an ICD
ated with a disease process should not be coded
code assigned to the visit.
separately.
• If a urine pregnancy test is performed, a rea-
• An upper respiratory infection (URI) is typ-
son for obtaining that test must be associated
ically associated with pharyngitis, rhinitis,
with a diagnosis, such as secondary amenor-
and cough. Pharyngitis, rhinitis, and cough
rhea (N91.1), menometrorrhagia (N92.0), or
each have a distinct ICD-10 code ( J02.9, J00,
abdominal pain (R10.10 if upper abdominal
and R05, respectively), but the code for URI
pain or R10.30 if lower abdominal pain).
( J06.9) is used because it encompasses these
2. Assign an ICD code that reflects the most
symptoms.
specific diagnosis that is known at the time. 9. When the same condition is described as both
• A patient’s diagnosis is gastroenteritis (K52.9). acute and chronic, code both and use the acute
If it is reasonably certain that it is viral, use the code first.
code for viral gastroenteritis, A08.4. Suppose • A patient may have an acute exacerbation
that the patient’s original complaint was di- ( J01.90) of chronic sinusitis ( J32.9).
arrhea (R19.7). The result of a stool culture is
positive for shigella. When the patient returns Accurate billing and coding is necessary to capture as
for a follow-up visit, then the diagnosis would much revenue as possible. The information presented
be enteritis, shigella (A03.9). here is meant to be illustrative in nature and is by no
3. The primary code should reflect the patient’s means adequate treatment of the subject and should not
chief complaint or the reason for the encounter. be relied on as authoritative. Many excellent resources
• A patient with a history of depression and are readily available to assist those who desire more
diabetes presents with acute abdominal pain. information on this topic.

Electronic Medical Records an electronic medical records system should be capable

of performing:
In just a decade, medical documentation has transi- 1. Health information and data
tioned from mostly paper records to mostly electronic 2. Result management
records. Much of the stimulus for adoption of EMRs 3. Order management
is the increasing evidence that current systems are not 4. Decision support
delivering sufficiently safe, high-quality, efficient, and 5. Electronic communication and connectivity
cost-effective health care. According to HHS, 78% 6. Patient support
of office-based physicians and 59% of hospitals use 7. Administrative processes
a basic EMR system. EMR lies at the center of any 8. Reporting
computerized health system. The EMR is a longitudinal
electronic record of patient health information gen- A closer look at the intended functionality in each
erated by one or more encounters in any care delivery of these eight areas identifies some of the perceived
setting. Several interchangeable terms may be used for benefits of EMRs. An electronic system would provide
EMR, such as electronic health record (EHR), electronic immediate access to key information, such as diagnoses,
patient record (EPR), and computer-based patient record allergies, laboratory test results, and medications, that
(CPR). A more comprehensive definition of EMR is would improve the provider’s ability to make sound
provided by the 1997 Institute of Medicine report, The clinical decisions in a timely manner. Result manage-
Computer-Based Patient Record: An Essential Technology ment would ensure that all providers participating in
for Health Care: the care of a patient would have quick access to new
and past test results, regardless of who ordered the
A patient record system is a type of clinical information tests, the geographic location of the ordering provider,
system, which is dedicated to collecting, storing, ma- or when the tests were ordered or performed. Order
nipulating, and making available clinical information management would include the ability to enter and
important to the delivery of patient care. The central store orders for prescriptions, tests, and other services
focus of such systems is clinical data and not financial in a computer-based system that would enhance leg-
or billing information. Such systems may be limited in ibility, reduce duplication, reduce fragmentation, and
their scope to a single area of clinical information (e.g., improve the speed with which orders are executed.
dedicated to laboratory data), or they may be comprehensive Using reminders, prompts, and alerts, computerized
and cover virtually every facet of clinical information decision-support systems would improve compliance
pertinent to patient care (e.g., computer-based patient with best clinical practices, ensure regular screen-
records systems). ings and other preventive practices, identify possible
The electronic storage of clinical information will create drug–drug or drug–disease interactions, and facilitate
the potential for computer-based tools to help providers diagnoses and treatments. Electronic communication
significantly enhance the quality of medical care and and connectivity would provide efficient and secure
increase the efficiency of medical practice. These tools communication among providers and patients that would
may include reminder systems that identify patients improve the continuity of care, increase the timeliness
who are due for preventive care interventions, alerting of diagnoses and treatments, and reduce the frequency
systems that detect contraindications among prescribed of adverse events. Patients would be provided tools that
medications, and coding systems that facilitate the give them access to their health records and interactive
selection of correct codes for patient encounters. The patient education and that would help them carry out
potential of such tools will not be realized, however, if home-monitoring and self-testing to improve control of
the EMR is just a set of textual documents stored in chronic conditions. Computerized administrative tools,
a computer, that is, a “word-processed” patient chart. such as scheduling systems, would improve hospitals’
To support intelligent and useful tools, the EMR must and clinics’ efficiency and provide more timely service to
have a systematic internal model of the information patients. Electronic data storage that employs uniform
it contains and must support the efficient capture of data standards will enable health-care providers and
clinical information in a manner consistent with this organizations to respond more quickly to federal, state,
model. and private reporting requirements, including those that
support patient safety and epidemiological and disease
surveillance. Such data could be readily analyzed for
Benefits of Electronic Medical Records medical audit, research, and quality assurance and could
A 2003 report by the Institute of Medicine, Key Capa- provide support for continuing medical education.
bilities of an Electronic Health Record System, identified Electronic prescribing, or e-prescribing, is a specialized
a set of eight core health-care delivery functions that function within a computerized medical record system.

Specific legislation and regulations exist that dictate such as patient records, cannot easily be shared across
the use of electronic prescribing. This is discussed in and sometimes within enterprises. There are signifi-
detail in Chapter 9. cant barriers to achieving interoperability. Incredibly,
there are over 1,000 EMR platforms on the market.
Barriers to Electronic Medical Records Most of these systems are highly proprietary and may
Many perceived barriers have hampered widespread not communicate well with each other. This lack of
implementation of EMRs. Although numerous studies interoperability presents a barrier to the transparent
have shown that most health-care providers believe that communication of health information, preventing
use of EMRs will improve quality of care, reduce errors, adequate coordination of care on the small scale and
improve quality of practice, and increase practice produc- obstructing population health management on a larger
tivity, there is resistance to adopting EMRs. A number scale. There is no standard technical language shared
of factors contribute to this, including well-publicized between systems; hence, there is little or no integra-
EMR failures; limited computer literacy on the part of tion with other applications, nor is there the ability
providers; concerns over security, productivity, patient of different systems to communicate in a meaningful
satisfaction, and unreliable technology; and the ab- way with one another. Information technologies were
sence of reputable research substantiating the benefits not initially designed with interoperability in mind, so
of EMR. Market and economic factors are a concern. rarely are structures in place to support it. Currently
Apart from the costs of hardware and software, there used data storage systems are often proprietary, and
is a tremendous cost in staff time and revenue when access to these systems is difficult. Implementation of
switching from paper to electronic charts. Ethical interoperable health information systems may require a
and legal issues abound with concerns about safety high degree of technical expertise not readily available
and security of systems and the ability to protect and to individual providers or smaller health-care organiza-
keep private confidential health information. There is tions. Standards of interoperability are only just being
even disagreement over who “owns” the data entered developed—after many health information technology
into any system as well as debate about accessibility to systems have already been installed and implemented.
the data. Technical matters, such as functionality, ease Meeting standards of operability will be an important
of use, and customer support from vendors are other criterion for the certification of EMR systems that are
barriers. It is challenging enough to find an EMR being developed at this time.
system that works for a single-provider ambulatory
care–based practice; it is another challenge altogether Meaningful Use
to find a system that will work for large institutions In February 2009, President Obama signed into law the
and serve the needs of diverse departments. Providers American Recovery and Reinvestment Act (ARRA) of
often complain that EMRs interfere with clinical 2009, which included more than $48 billion for health-care
care, making interactions more impersonal and less information technology for the adoption and effective use
face-to-face while also degrading clinical documentation. of EMR and for regional health information exchange.
Despite the huge investments that have been made in The Health Information Technology portion of ARRA
new technology, there are conflicting opinions about contains information related to the Health Information
the value of EMRs and whether or not they will truly Technology for Economic and Clinical Health Act
help improve quality of care while decreasing costs. A (HITECH); the HITECH Act offers financial incen-
recent study by Medical Economics indicated that 67% tives for health-care providers and hospitals that comply
of physicians are displeased with their EMR systems. with the standards of “meaningful use.” To receive an
incentive payment, providers have to show that they are
Interoperability “meaningfully using” their certified EMR technology
Perhaps the biggest barrier to widespread adoption of by meeting certain measurement thresholds that range
EMR is lack of interoperability. A basic definition for from recording patient information as structured data to
interoperability is the ability of two or more systems or exchanging summary care records. The HITECH Act
their components to exchange information and to use imposes requirements for notification of a data breach
the information that has been exchanged. As it relates related to unauthorized uses and disclosures of “unsecured
specifically to EMRs, the Healthcare Information protected health information” (PHI). These notification
and Management Systems Society (HIMSS) defines requirements are similar to many data breach laws at
interoperability as “the ability of health information the state level related to personally identifiable financial
systems to work together within and across organizational information (e.g., banking and credit card data). Under
boundaries in order to advance the effective delivery of the HITECH Act, unsecured PHI essentially means
health care for individuals and communities.” Without “unencrypted PHI.” In general, the Act requires that
interoperability, fundamental data and information, patients be notified of any unsecured breach. If a breach

impacts 500 patients or more, then HHS also must be may be excluded for 18 months. If a person had health
notified. Notification will trigger posting the breaching insurance coverage before enrolling in a new health plan,
entity’s name on HHS’ website. Under certain conditions, the exclusion period may be reduced by the number
local media also will need to be notified. Furthermore, of months a person was insured, as long as there were
notification is triggered whether the unsecured breach no significant breaks of 63 or more days of coverage.
occurred externally or internally. Title I has additional important provisions. Pre-existing
conditions do not apply to pregnancy or to a child en-
rolled within 30 days of birth or adoption. Insurers are
Health Insurance Portability required to renew coverage to all groups regardless of
and Accountability Act the health status of any group member. Insurers may
not establish any rule that discriminates based on the
(HIPAA) health status of an individual or his or her dependent,
nor may they charge higher premiums or alter the level
Confidentiality of medical records has always been a of benefits. For those individuals with their own pri-
concern for health-care providers. Regardless of the vate health insurance plan, renewability is guaranteed.
medium of storage, confidentiality of data contained in Coverage cannot be terminated unless the premiums
the records will continue to be of utmost importance. are not paid, fraud is committed against an insurer, the
With the emphasis on interoperability and the criteria policy is terminated by the insured, the insured person
that define how EMR systems must be able to exchange moves outside the service area of a network plan, or the
confidential medical information securely, a discussion insurance is available only to members of that association
of the Health Insurance Portability and Accountability and membership in the association is ended. If the insur-
Act (HIPAA, or the Act) is warranted. ance company stops selling the policy, it must offer the
Enacted by Congress in 1996 to address a number insured another policy it sells in the same state. Further
of issues affecting national health care, HIPAA is a details may be found at http://healthcare.findlaw.com/
large and complex law continually subject to revi- patient-rights/hipaa-the-health-insurance-portability-
sions and amendments by legislative actions. The Act and-accountability-act.html.
establishes standards, and timetables for adoption of
the standards, for electronic transfers of health data, Electronic Health-Care Transactions
addressing growing public concern about privacy and Prior to implementation of HIPAA, it was estimated
security of personal health data. The primary goals of that about 400 different formats were being used to
the standards are (1) to combat fraud and abuse; (2) to process health claims online. Billing and other adminis-
make health insurance more affordable and accessible; trative procedures were inconsistent and varied among
(3) to simplify administration of health insurance claims health insurers, the government, and other entities. This
by requiring all entities to bill electronically using one made it difficult for providers, hospitals, health plans,
format; (4) to give patients more control of and access and health-care clearinghouses to process claims and
to their health-care information; and (5) to protect perform other transactions electronically. In an effort
medical records and individually identifiable medical to lower costs and improve efficiency, standards were
information from unauthorized use or disclosure, es- developed to simplify the administration of health in-
pecially in the burgeoning electronic age. surance claims by requiring common formats adopted
as national standards under HIPAA. The standards
Health Insurance Portability require that the same format is used to transmit the
The Health Insurance Portability provision of the Act following health-related information:
(Title I) improves the portability and continuity of
• Claims and equivalent encounter information
health insurance coverage for workers and their families
• Claim status
when they change or lose their jobs by limiting the re-
• Payment and remittance advice
strictions that a group health plan can place on benefits
• Enrollment and disenrollment in a plan
pertaining to a pre-existing condition. A pre-existing
• Eligibility for a plan
condition is a condition for which medical advice, diag-
• Premium payment
nosis, care, or treatment was recommended or received
• Referral certification and authorization
within the 6 months before the enrollment date for a
• Coordination of benefits
new health insurance plan. Pre-existing conditions can
be excluded from health benefits for only 12 months.
A person who did not enroll during the initial or open The Privacy Rule
enrollment period is considered a late enrollee, and Providers have an ethical and legal obligation to safe-
benefits for late enrollees with pre-existing conditions guard patients’ privacy. Because of the requirements of

transmitting sensitive health information electronically, business associate, there must be an agreement that
the Privacy Rule was written to protect the confidenti- the PHI will be handled according to federal and state
ality of individually identifiable health information. The privacy laws. Additionally, a CE may disclose PHI as
rule limits the use and disclosure of certain individually required by law, such as reporting child abuse to state
identifiable health information; gives patients the right child welfare agencies. Treatment covers a wide array of
to access their medical records; restricts most disclosures patient-related activities, including providing health care,
of health information to the minimum needed for coordinating services, referring patients, and consulting
the intended purpose; and establishes safeguards and among providers. Communication between CEs may
restrictions regarding the use and disclosure of records take place using any method, including oral, written,
for certain public responsibilities such as public health, electronic mail, or facsimile, as long as “reasonable and
research, and law enforcement. Under the rule, improper appropriate safeguards” are used to protect the information.
uses or disclosures may be subject to criminal or civil Payment includes activities relating to financial aspects
sanctions prescribed in HIPAA. Federal HIPAA regu- of health care. PHI can be used for billing and claim
lations do not pre-empt any state laws that are stronger processing to obtain reimbursement and for utilization
or more protective of consumers’ security and privacy. review. Health-care operations include a wide range of
administrative and management activities in which CEs
Protected Health Information engage. These include case management and patient care,
and Covered Entities risk management, legal services, credentialing, quality
PHI relates to the past, present, or future physical or assessments and outcomes development, guidelines and
mental health or condition of an individual; the provision protocol development, and training students. Sensitive
of health care to an individual; past, present, or future PHI includes information about certain conditions or
payment for the provision of health care to an individual; their associated treatment, such as HIV status, substance
and information that identifies or could reasonably be abuse, or mental health conditions. Use of PHI refers to
used to identify a protected individual. This information internal use by the CE; disclosure refers to sharing of PHI
may be oral, electronic, paper, or any other form. Individ- for external purposes. Sensitive PHI may not be disclosed
ually identifiable health information includes such data without a patient’s written authorization, except in certain
as name, Social Security number, patient identification circumstances, such as to a consultant who needs this
number (such as a medical record number), address, information to assist in the patient’s health care.
demographic data, or any other information that could Consent Versus Authorization
reasonably allow a person to be identified.
The Privacy Rule applies only to covered entities Consent must be obtained from the patient at the first
(CEs) that transmit medical information electronically. visit before any services are provided. Patients must sign
There are three categories of CEs: (1) health-care pro- a consent form stating that they have been notified
viders, such as doctors, clinics, psychologists, dentists, of the practice’s privacy policy, which explains that
chiropractors, nursing homes, and pharmacies; (2) health the practice may use and disclose PHI for treatment,
plans, including health maintenance organizations payment, and health-care operations. Consent needs to
(HMOs), health insurance companies, and government be obtained only once and is valid until revoked by the
programs that pay for health care, such as Medicare, patient in writing. In an emergency situation, treatment
Medicaid, and the military and veterans’ health-care may be rendered without consent, but consent should
programs; and (3) clearinghouses that electronically be obtained as soon as possible afterward.
transmit medical information, such as billing, claims, For all other uses and disclosures, unless required
enrollment, or eligibility verification. by law, specific authorization must be obtained from
the patient detailing what PHI may be disclosed, to
whom it may be disclosed, and an expiration date. An
Use and Disclosure of Protected authorization is needed to release PHI to life insurance
Health Information companies and patients’ legal counsel. A CE may not
HIPAA has very prescriptive language for the use and give or sell patients’ names for commercial or marketing
disclosure of PHI. A CE may use or disclose PHI purposes. For example, a CE may not give or sell names
without patient authorization for purposes of treatment, of allergy sufferers to pharmaceutical companies that
payment, or its health-care operations. This includes dis- market allergy products.
closures to its agents or to another CE, such as another
health-care provider. Agents are business associates who Individual Rights
perform a function for the CE, such as dictation, legal Patients have the right to review and obtain a copy of
services, billing, and accounting, and are not subject their medical records, except in certain circumstances.
to the Privacy Rule. When a CE discloses PHI to a Exceptions to the rule are psychotherapy notes, information

compiled for lawsuits, and information that, in the opin- health-care provider judges it to be in the patient’s best
ion of the health-care provider, may cause harm to the interest and as long as the patient has not restricted the
patient or another individual. A reasonable, cost-based release of information to that person.
fee may be charged to cover expenses for copying and
postage. If a medical summary of the record is requested, Minors
the fee should be agreed on beforehand. Patients also The Privacy Rule defers to state or other applicable
have the right to request an amendment or correction laws that address the ability of a parent or guardian
if they feel the record is inaccurate or incomplete and to obtain health information about a minor child. In
may submit a written supplement to be included in their most cases, the parent represents the child and has the
record. If the health-care provider declines the request, authority to make health-care decisions about the child;
the provider must do so in writing and allow the patient however, the Privacy Rule specifies three circumstances
to submit a statement of disagreement for inclusion when certain minors may obtain specified health care
in the record. However, the health-care provider must without parental consent:
allow the patient to submit a correction to be placed in
• When state or other law does not require the
the medical record. The CE also may include its own
consent of a parent before a minor can obtain a
rebuttal. A health-care provider may require a patient
particular health-care service, and when the mi-
to come into the office during normal business hours
nor consents to the health-care service. Example:
to access and inspect the record. The provider also may
A state law provides an adolescent the right to
arrange to have someone present who can answer any
obtain mental health treatment without the con-
patient questions or concerns.
sent of the parent, and the adolescent agrees to
Patients have a right to an accounting of certain PHI
such treatment without the parent’s consent.
disclosures by a CE. The CE must be able to report who
• When a court determines, or other law autho-
the recipient was, when the disclosure was made, and
rizes, someone other than the parent to make
for what purpose the disclosure was made. The maximal
treatment decisions for a minor. Example: A court
accounting disclosure period is the 6 years preceding
may grant authority to an adult other than the
the request. Exceptions to this rule include disclosures
parent to make health-care decisions for the mi-
for treatment, payment, or health-care operations; to
nor, such as a stepparent or guardian.
the individual or their representative; pursuant to an
• When a parent agrees to a confidential relation-
authorization; and for national security purposes.
ship between the minor and the physician. Exam-
CEs must take reasonable steps to ensure the con-
ple: A physician asks the parent of a 16-year-old if
fidentiality of communications with the patient. The
the physician can talk with the child confidentially
record should demonstrate how the patient would
about a medical condition and the parent agrees.
prefer to be contacted regarding PHI, including test
results, appointment reminders, or discussions regarding Even in these circumstances, the Privacy Rule defers
his or her medical care. The patient may request to be to state or other laws that require, permit, or prohibit
contacted at an alternative address or telephone number. the CE to disclose to a parent, or provide the parent
A health-care provider may share relevant information access to, a minor child’s PHI. When the laws are un-
with family, friends, or caregivers involved in a patient’s clear, a licensed health-care professional may exercise
health care as long as the patient does not object and professional judgment on whether to provide or deny
the provider feels it is in the patient’s best interest. In- parental access.
formation may not be disclosed to a person not involved When a health-care provider reasonably believes
in the patient’s health care, if disclosure is judged to be that disclosure of PHI to the personal representative
inappropriate by the provider, or if the patient requests who is authorized to make health-care decisions for
nondisclosure. When disclosing PHI, only the minimal an individual may not be in the patient’s best interest,
information needed by that particular person should the provider may choose not to disclose, especially in
be disclosed; for example, a caregiver needs to know situations in which abuse, neglect, and endangerment are
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dietary instructions are prescribed, and what changes in that disclosing information about an incompetent older
condition to report. Details about the patient’s diagnosis individual to the individual’s personal representative
and prognosis may not be necessary and should not be would endanger the patient, the Privacy Rule permits
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personal representative. A family member or friend
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Edition, (Ebook PDF)

Copyright © 2019 by F. A. Davis Company. All rights reserved. vii

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Part 1: Foundations of Documentation

Part II: Documentation Related to Outpatient Care

Part III: Documentation Related to Inpatient Care

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Part 1: Foundations of Documentation

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Chapter 2 The Comprehensive History and Physical Examination 23

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Part II: Documentation Related to Outpatient Care

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Documenting Preventive Care 126

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Chapter 8 Outpatient Charting and Communication 173

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Part III: Documentation Related to Inpatient Care

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Vital Signs 227

Chapter 11 Documenting Inpatient Care 257

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Consult Note 266

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Copyright © 2019 by F. A. Davis Company. All rights reserved. xxi

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documentation and puts a greater burden on providers

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Application Exercise 1.1

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EXAMPLE 1.1  mortality and morbidity statistics. These standardized

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Electronic Medical Records an electronic medical records system should be capable

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EXAMPLE 1.1 mortality and morbidity statistics. These standardized