JThomas_HealthrecordDocGuidlines_111923
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School
Rasmussen College, Florida *
*We aren’t endorsed by this school
Course
M208/HIM20
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
3
Uploaded by chloeyjodi
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
To be completed at time of seeing patient
To include patients past and current diagnosis, procedures, family history and the
appearance of the patient at the time of exam.
2. Operative Report
Immediately after procedure
Attending surgeons, time, date, procedure performed, details of procedure in report
3. Discharge Summary
Upon Discharge
Reason for visit, at home care, at home medications, information pertaining to
patients’ reason for visit.
4. Circumstances that allow a Final Progress Note to replace a Discharge Summary.
Death
5. Circumstances that necessitate a Pathology Report.
Concerns of change from last pathology
To review Findings of the pathology report
6. Timing requirements for Progress Notes.
Immediately upon evaluation of patient
7. Minimum content requirements for a Progress Note.
Patients’ current health status, any changes.
Jodi Thomas
Module
02
Assignment
–
Health Record Documentation Guidelines
Current and future Care plan
Date, Time patients’ current location
8. Proper step by step methodology for correcting errors in patient record documentation.
Number and record the steps.
Use a permanent ink pen, put a single line through what needs to be corrected, write
“error”, correct it accordingly and initial.
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.)
Policies established to manage patient information
10. Define Legal Health Record (your own words for credit.)
A legal Health Record is any record that has a person’s personal information within
the record, including medical history, Demographics, procedure reports etc. It is a
record that has been signed by a Physician
11. Define Administrative health data
Information collected and processed by Administration parties about an individual
person
Insurance Information and claims
Patient demographics
12. Define Clinical health data
Health care related information pertaining to patient care
Progress Notes
Procedure Reports
Jodi Thomas
Module
02
Assignment
–
Health Record Documentation Guidelines
Reference:
Gordon, N.S. L. (2020). Health Information Management Technology: An Applied Approach
(6th ed.). American Health Information Management Association (AHIMA).
https://ambassadored.vitalsource.com/books/9781584267645
Jodi Thomas
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