During a chart audit, you come across the following note for…
During a chart audit, you come across the following note for a 72-year-old patient admitted with confusion and right arm weakness: “Neuro exam intact.” Based on weeks 1–5 content, identify at least three components of a focused neurological assessment that should have been documented in this patient. (3 points) Explain why the documentation “neuro exam intact” is inappropriate in this case, and describe one specific system-level risk that arises when vague documentation is used. (2 points)
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