HIM2000 Module 02 Health Record Documentation Guide (1)
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School
Rasmussen College *
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Course
M208/HIM11
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by shavonloupe
Module
02
Assignment
–
Health Record Documentation Guidelines
Rasmussen Medical Center
Policy:
Health Record Documentation Requirements
Approval Date:
xx/xx/xxxx
Policy Group:
Medical Staff Bylaws
Instructions:
Type your responses below and submit the completed template to the
assignment dropbox for grading. Be sure to thoroughly complete
Part One
and
Part Two
of
the
Health Record Documentation Guide
.
Part One:
Detail the major topics listed below that relate to medical staff documentation
requirements for the policy. Use complete sentences to prepare a professional submission.
1.
Medical History and Physical Examination
The completion of the medical history and the physical examination must be
completed by the time the service described is rendered.
2.
Operative Report
The completion of the operative report must be completed at the time the services
are rendered, or they must be dictated 24 hours before a procedure.
3.
Discharge Summary
The completion of the discharge summary must be done before the patient will be
discharged or at the time the patient is discharged.
4.
Circumstances that allow a Final Progress Note to replace a Discharge Summary.
The final progress note can be used in the place of a discharge summary when the
discharge summary is waiting to be completed from the dictation.
5.
Circumstances that necessitate a Pathology Report.
The pathology report must be presented each time that a biopsy is completed.
Module
02
Assignment
–
Health Record Documentation Guidelines
6.
Timing requirements for Progress Notes.
The progress notes must be recorded and completed each time an encounter with a
patient occurs. It must be completed within 48 hours of a face-to-face encounter.
7.
Minimum content requirements for a Progress Note.
The progress notes should include all test performed, vitals, medication refills,
reviews of symptoms, and any progress the patient has made.
8.
Proper step by step methodology for correcting errors in patient record
documentation. Number and record the steps.
Any errors that need to be corrected must be made by adding addendum to the HER.
No changes can be made on original entries in any documents.
Part Two:
Using your own original words
(do not copy from course content or any resource),
complete 9-12 for the policy.
9.
Define information Governance (your own words for credit.)
Governance is how to share any data or type of information in the appropriate way.
10. Define Legal Health Record (your own words for credit.)
Legal Health Record is a documentation of health information that is created by a
healthcare organization.
11. Define Administrative health data
Administrative health data is the data that an organization collects. Two examples of
this is payment and planning.
12. Define Clinical health data
Clinical health data is clinical information data that is collected and documented from
health services. Two examples are the diagnosis and the treatment.
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