Question

HIM

1.13 Health record completion ldentify a complete health record according to, organizational policies external regulations, and standards Subdomain l.B.3 G As an HIM chart analyst, you are reviewing the chart of a patient who was admitted on 2/17 with gallstone pancreatitis. She arrived through the emergency roo afternoon in severe abdominal pain. After lab work was performed showing an increased lipase level, she was admitted. Her family physician evaluated her the next morning and ordered an ultrasound, and repeat lab work. The ultrasound showed gallstones and the lab work indicated the lipase was coming down. He consulted a general surgeon who evaluated the patient and agreed to perform a cholecystectomy on Friday if the lipase level returned to near normal levels. Surgery was then performed on Friday morning, and after an uneventful night, the patient was discharged home on Saturday morning. On 2/25, you have the following documentation available in the EHR Wednesday authenticated 2/18 authenticated 2/23 authenticated 2/19 authenticated 2/21 authenticated dictated 2/18 dictated 2/18 written 2/19 dictated 2/20 dictated 2/22 H&P Consultation report Immediate post-op note Operative report Discharge summary Lab work from all dates of stay Nursing notes from all dates of stay Anesthesia documentation from surgery Physician orders from all dates of stay -all signed Progress notes-all signed Medication list-signed ib nsbus hu slH You analyze the above information and identify that the record is not complete. 1. List the reason(s) for your determination of an incomplete record 2. List the steps that must be taken to get the record complete in the required time frame

Answer 1

• The above record is obviously incomplete. This is due to the following reasons: discharge summary has not been authenticated, nursing and anesthesia records haven't been cross checked and authenticated
• All the necessary departments must be contacted and asked to rectify the records. Discharge papers must be authenticated, patient data entered into the electronic health record system, lab works from all days compiled and analysed, physician orders noted and cross checked, progress and medication records compiled.