Develop a well-thought answer discussing various elements that should be analyzed and evaluated in the medical...
Develop a well-thought answer discussing various elements that should be analyzed and evaluated in the medical record to ensure proper documentation that conveys the patient’s diagnoses, procedures performed, clinical findings, and discharge status.
Homework Answers
A good documentation practice is important in every procedure, especially in medical records. There are various factors in determining the good characteristics of a medical record. It should be,
1. Accurate
2. Comprehensive
3. consistent
4. Timely prepared
5. Complete
6. Relevant
A good document should meet the above-mentioned parameters. The diagnoses and treatments are done for each patient are different. Therefore collecting and segregating the accurate information needs a lot of effort and patience. All the clinical findings must be included in the medical record and should be in a proper manner from beginning to end. Patient discharge data also consider very importantly; therefore it should be clearly mentioned in records.
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Develop a well-thought answer discussing various elements that
should be analyzed and evaluated in the medical...
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The activity
You are the Health Information Director at the General Hospital,
which has been accredited by The Joint Commission (TJC). You have
been notified that surveyors are currently onsite and, as part of
their survey process, are utilizing the tracer methodology. They
will be evaluating the direct care of patients currently admitted
to the hospital and will also need access to the hospital’s
EHR.
One of the patients whose care and medical record the surveyors
will be examining is...
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The activity
You are the Health Information Director at the General Hospital,
which has been accredited by The Joint Commission (TJC). You have
been notified that surveyors are currently onsite and, as part of
their survey process, are utilizing the tracer methodology. They
will be evaluating the direct care of patients currently admitted
to the hospital and will also need access to the hospital’s
EHR.
One of the patients whose care and medical record the surveyors
will be examining is...
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