every report and every page/screen in a manual or computerized patient record must include:google

What must be on the front page of a patient record?

Only the front page of a two-page document must contain patient identification. b. An alias cannot be used in a patient record. c. All entries must be legible and complete.

What is a computer-based patient record?

A computer-based patient record can link patient information at different locations according to a unique patient identifier. Suzy Supervisor is working to transition the health information management (HIM) department from a paper system to an electronic system.

What are the rules for documentation of patient records?

All entries should be documented and signed by the author. 2. Complete only necessary entries on preprinted forms. Leave others blank. 3. If other patient (s) are referenced in the record, document their name (s).

What is a medical record number used for?

Typically, a patient's medical record number is used as the unique identification number when documents are scanned into automated systems. A computer-based patient record can link patient information at different locations according to a unique patient identifier.

What do we call patient physiological data that is electronically sent from the field to the hospital?

An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, ...

Who generally owns the medical record?

The U.S. does not have a federal law that states who owns medical records, although it is clear under the Health Insurance Portability and Accountability Act (HIPAA) that patients own their information within medical records with a few exceptions.

Which of the following would provide a glimpse of the fluctuation of the patient's blood pressure during the 5 day hospital stay?

Which of the following would provide a glimpse of the fluctuation of the patient's blood pressure during the 5-day hospital stay? Vital Signs Record.

Which term best describes medical services that meet professional medical standards?

What is a premium? Which term best describes medical services that meet professional medical standards? medical necessity.

What is included in medical report?

It includes informationally typically found in paper charts as well as vital signs, diagnoses, medical history, immunization dates, progress notes, lab data, imaging reports and allergies. Other information such as demographics and insurance information may also be contained within these records.

Who is responsible for a patient's healthcare record and why?

There are 21 states in which the law states that medical records are the property of the hospital or physician. The HIPAA Privacy Rule makes it very clear that, with few exceptions, patients should be given access to their records, in a timely matter, and at a reasonable cost.

Which of the following contains chronological documentation of the patient's illness and responses to treatment?

The health record is a chronological documentation of health care and medical treatment given to a patient by professional members of the health care team and includes all handwritten and electronic components of the documentation.

What is the role of information technology in the health care industry?

In the healthcare sector, information technology has played a crucial role in providing a central database to manage patient data in the form of Electronic Health Records (EHR) and modern software that helps to simplify medical billing and coding and streamline the financial revenue cycle.

Why is it important for vital signs to be measured and recorded accurately?

Tracking your vital signs provides medical professionals with concrete information that they use to assess your health and form a correct diagnosis. Without vital signs, misdiagnosis can occur and lead to incorrect treatment.

Which of the following options includes health maintenance organizations and preferred provider organizations?

Managed care plans include health maintenance organizations, preferred provider organizations and point-of-service plans.

Which is responsible for reviewing health care provided by managed care organizations?

Accreditation: a systematic review of a managed care plan by one of three private, non-profit agencies (the National Committee for Quality Assurance, the Joint Commission on the Accreditation of Health Care Organizations, and the American Accreditation HealthCare Commission/Utilization Review Accreditation Commission).

What type of managed care model has a contracted network of health care providers that provide care to subscribers for a discounted fee?

Chapter 3 InsuranceQuestionAnswerContracted network of health care providers that provide care to subscribers for a discounted fee.PPOOrganization of affiliated providers' sites that offer joint health care services to subscribers.IDS16 more rows

What is a complication in medical terms?

A complication is a preexisting condition that will cause an increase in the patient's length of stay by at least one day. False. A consent to admission documents a patient's consent for all medical treatment including procedures and surgeries to be completed during the current admission. True.

Can a discharge progress note be documented in a patient record?

A discharge progress note can be documented in a patient record instead of a discharge summary if a patient had an uncomplicated hospital stay of less than 48 hours. True. A licensed nurse is required to have a public license to deliver care to patients.