Question

CASE 1-23 Abstract of Pertinent Inpatient Medical Documentation Ith data items fre- ind indicate from cely find the inpatient an HIM manager at a Critical Access Hospital (CAH). Find below a list of health data in quchd accessed for reporting purposes in hospitals. Review the list of data requested and indir which medical report or electronic health record (EHR) screen you would most likely find the ini record data. atives prior to a particular 1. Patient demographic data 2. Evidence that the patient was informed of benefits, risks, and alternatives prior to a na surgery 3. Reason for admission and review of body systems 1. An evaluation of patient prior to induction of anesthesia 5. Chest radiology interpretation 6. Name of surgeon and assistant surgeon, and estimated blood loss 7. Family and social history 8. CBC and urinalysis test results 9. Course of events throughout hospital stay 10. Vital signs; fluid input and urine output 11. Chronological entries made about patient's condition by nurses 12. Chronological entries made about patient's condition by physician 13. Patient's blood type and Rh factor 14. Discharge diagnosis and discharge instructions with follow-up care 15. Date, time, name of drug; drug dose and route of administration 16. Name of person designated by patient to make healthcare decisions should patient become incapacitated

Answer 1

All the details mentioned are found in multiple documents as mentioned.

1 Patient Demographic data : Face sheets , Demographics

2. Benefits, risks of surgery : Informed consent forms and also procedure forms.

3. Reason for admission and review of body systems : Emergency Department summary reports.

4. Evaluation of patient prior to induction of Anaesthesia : Anaesthesia reports (preprocedural care)

5. Chest Radiology interpretation : Radiology reports or Imaging.

6. Name of the surgeon and assistant surgeon and estimated blood loss.

All the surgical reports , Provider names tab and the surgical procedure reports.

7. Family and Social history

History tabs - Psychosocial and family histories.

8. CBC and urinalysis test results - Laboratory reports

9. Course of events through out hospital stay

Nurses notes, ED event notes

10. Vital signs , fluid input and urine output

Vital signs tab, All notes, I and O chart tabs

11. Chronological entries about patient by Nurses

Nurses Notes

12. Entries made by physician.

All physician documentations

13. Patient blood type and Rh factors

  Admission notes, laboratory reports

14 Discharge diagnosis and discharge instructions

Discharge summary , Discharge education notes

15.Date time name and route of the drugs

Medication orders

Medication Administration Records

16. Name if the health care designated person of decision making

All reports especially ED , progress notes, consultations.