Question

As the him director, you are required to write a policy and procedure on the comprehensive...

As the him director, you are required to write a policy and procedure on the comprehensive documentation required in the medical record for your acute care hospital. the document should include when the report is required at the facility and the timeliness, content, and author for the following: a. history and physical b. discharge summary c. operative report

(A sample to compare on how to put this together is needed)

0 0
Add a comment Improve this question Transcribed image text
Answer #1

Policy is - every patient those have acute condition must ask about about of condition at the time of event and before , vitals at time of acute event , minimum time a patient take for stabilisation in different condition, different procedure history , duration of stay in hospital, any other acute event during hospital stay with discharge summary and improment in next visit or some time after to discharge from hospital

Add a comment
Know the answer?
Add Answer to:
As the him director, you are required to write a policy and procedure on the comprehensive...
Your Answer:

Post as a guest

Your Name:

What's your source?

Earn Coins

Coins can be redeemed for fabulous gifts.

Not the answer you're looking for? Ask your own homework help question. Our experts will answer your question WITHIN MINUTES for Free.
Similar Homework Help Questions
  • imagine you are the HIM Director at an acute care facility in your local city. You...

    imagine you are the HIM Director at an acute care facility in your local city. You have been asked to serve on a committee to create a program and develop policies that support a culture of diversity at the facility. what would you include in your program? What policies might you create? Write an outline for your program and a summary of three policies you would create for the program, and explain why this program and these policies are important...

  • The acute care facility inpatient record contains numerous reports that are documented by various facility personnel...

    The acute care facility inpatient record contains numerous reports that are documented by various facility personnel and medical staff providers. Each facility establishes a filing order for inpatient and discharged patient reports to ensure that information can be easily located in the record. This assignment will familiarize you with the content of an inpatient record and the typical order of reports filed in a discharged patient record. Instructions: 1. the chart below contains a list of acute care discharged patient...

  • For this activity, you should review all of the different types of records (H&P, Discharge Summary, X-Ray, etc) in c...

    For this activity, you should review all of the different types of records (H&P, Discharge Summary, X-Ray, etc) in chapter 6 and pay attention to the different types of information are in each record. For example, if you look at the Electroenceophalogram Report on page 194, you can see that some of the parts of the record include the Patient Age, EEG #, History, Medications, Conditions of Recording, and Impression. All of these different record parts are required in this...

  • COUCO which a comprehensive and medical decision which a comprehensive on were performed and made until after the...

    COUCO which a comprehensive and medical decision which a comprehensive on were performed and made until after the initial i a. True b. False 2.26. Select the appropriate E/M code for a new patient office visit in which a ce history and comprehensive physical examination were performed and medienensya making was of straightforward complexity. - 2.27. Select the appropriate E/M code for an established patient visit in which a con history and expanded problem-focused physical examination were perform medical decision...

  • Section 5 • COMPLIANCE ASE 5-13 Documentation Improvement Laura just finished a documentation audit for the HIM depa...

    Section 5 • COMPLIANCE ASE 5-13 Documentation Improvement Laura just finished a documentation audit for the HIM department at the hospital where she works. She not surprised to learn that there were significant documentation problems. The top four problems deres were the following: • History and physicals (H&Ps do not meet medical staff bylaws for time of completion and content • Discharge summaries do not meet Joint Commission, Centers for Medicare and Medicaid guidelines documentation, and medical staff regulations for...

  • KEY ASSESSMENT: Strategic Planning Assessment Instructions: You work for a large acute care hospi...

    KEY ASSESSMENT: Strategic Planning Assessment Instructions: You work for a large acute care hospital designated as a level 1 trauma center. Leadership is considering opening an outpatient rehabilitation center for traumatic brain injury patients. The CEO has asked that HIM run a report identifying the number of TBI patients (consider what data will identify these patients) admitted to the facility in the last year, their discharge disposition and length of stay (consider how LOS is calculated - what data is...

  • Pearson Comprehensive Medical Coding Chapter 28

    Established patient office visit with a comprehensive history, comprehensive examination, and high-complexity medical decision making, resulting in a decision for major surgery the next day. CPT Code(s)                                                                                                            A 45-year-old male presents to the ER, where an open fracture of the left radius is diagnosed. Patient is admitted and ER physician requests surgery consult. Surgeon performs comprehensive history, comprehensive examination, and medical decision making of high complexity. Surgery is scheduled for the next day. (Code for the surgeon only). CPT Code(s)                                                                                                            A new...

  • Mr. Aburu, 81, with a history of cerebral vascular accidents, was hospitalized as an outpatient for a surgical procedure...

    Mr. Aburu, 81, with a history of cerebral vascular accidents, was hospitalized as an outpatient for a surgical procedure to incise and drain a skin lesion on his chest. After the procedure, he returned to the long-term care facility with sterile packing in the partially sutured incision site. The packing was to remain for 3 days, then be removed, and the wound covered with a dry dressing. The risk of complications for this type of surgery was considered quite low,...

  • Case 5-8 Physician Query Policy You have suspected there are problems in the physician query process...

    Case 5-8 Physician Query Policy You have suspected there are problems in the physician query process for a while now, and you have planned to review the policy and query form to look for any compliance issues. You would rather find the problems yourself before the Office of the Inspector General (OIG) finds them. Your task today is to evaluate the physician query process at your facility. Figures 5-1 and 5-2. Evaluate Figure 5-1 on all aspects including the following:...

  • CPT CODING Evaluation and Management Coding 1. A new patient is seen in the office for...

    CPT CODING Evaluation and Management Coding 1. A new patient is seen in the office for otalgia. The history is problem focused, the examination is problem focused, and the medical decision-making complexity is straightforward. Code:     2. An established patient is seen in the office for otalgia. The history and exam is expanded problem focused and the medical decision-making component is straightforward. Code:    3. An established patient is seen in the office for suture removal that is done by the physician’s...

ADVERTISEMENT
Free Homework Help App
Download From Google Play
Scan Your Homework
to Get Instant Free Answers
Need Online Homework Help?
Ask a Question
Get Answers For Free
Most questions answered within 3 hours.
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT