Documentation Requirements for the Acute Care Inpatient Record

?Documentation Requirements for the Acute Care In enduring exhibit (AHIMA manage Brief) ? The medical examination track record is a tool for collecting, storing, and processing longanimous information. Records are being used daily for a military of purposes, including: ? providing a means of communication between the physician and the some other members of the healthcare team caring for the patient ? providing a basis for evaluating the sufficiency and appropriateness of care ? providing data to substantiate insurance claims ? protecting the effective interests of the patient, the facility, and the physician ? providing clinical data for research and education ?General Guidelines for Patient Record Documentation ? Each hospital should have policies that ensure uniformity of both content and format of the patient record based on all applicable accreditation standards, federal and state regulations, payer requirements, and headmaster practice standards. ? The patient record should be organized consistently to facilitate data retrieval and compilation. ? Only persons authorized by the hospitals policies to document in the patient record should do so. This information should be recorded in the medical staff rules and regulations and/or the hospitals administrative policies.

? hospital policy and/or medical staff rules and regulations should specify who may receive and transcribe a physicians communicatory orders. ? Patient record entries should be documented at the cartridge clip the treatment they describe is rendered. ? Authors of all entries should be clearly identifiable. ? Abbreviations and symbols in the patient record are permitted only when approved agree to hospital and medical staff bylaws, rules, and regulations. ? All entries in the patient records should be permanent. ? Errors should be corrected as follows: draw a single line in ink through the ill-judged entry, and print error at the top of the entry with a legal signature or initials, date,... If you want to get a full essay, order it on our website: Orderessay

Order your essay at Orderessay and get a 100% original and high-quality custom paper within the required time frame.