review the following patient record entry, and determine in which report it would be documented.

What are the different parts of the patient record?

Sally Jones assembles the patient record and organizes the following documents into a separate section of the record: facesheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered:

How should documentation of patient information be entered?

If other patient (s) are referenced in the record, document their name (s). 4. All documentation should be entered in permanent black ink. 5. Be sure to document specific information and to avoid vague entries. a. b. d. Review the following patient record entry, and determine in which report it would be documented.

What should I do if other patients are referenced in records?

If other patient (s) are referenced in the record, document their name (s). 4. All documentation should be entered in permanent black ink. 5. Be sure to document specific information and to avoid vague entries.

What makes a patient record admissible in court?

The Uniform Rules of Evidence states that for a record to be admissible in court of law, all patient record entries must be dated and timed. The admitting diagnosis is the condition or disease for which the patient is seeking treatment.

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.

When should health record entries be recorded?

When should patient record entries be documented? Patient record entries should be documented as soon as possible after care is provided so as to increase accuracy of information recorded.

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.

How do you document a medical record?

The basics of clinical documentationDate, time and sign every entry. ... Write your name and role as a heading and the names and roles of all others present at the encounter.Make entries immediately or as soon as possible after care is given. ... Be legible. ... Be thorough, accurate, and objective.Maintain a professional tone.More items...•

What is an examination and review of patient records?

Audit. A record means to examine and review a group of patient records for completeness and accuracy.

What are the five C's for correctly entering information into a medical record?

What are the five C's for correctly entering information into a medical record?... Concise. Complete. Clear. Correct. Chronologically ordered.

Who owns the medical records or the patient's chart?

doctorsTraditionally, a patient's medical information has been segmented into charts that exist in various places – the offices of the doctors involved, hospitals, etc. Each doctor's chart is a medico-legal record of the advice given to the patient by the doctor, resides in the doctor's office, and is “owned” by the doctor.

What are some methods of documentation of patient education?

Five Steps for Effective Documentation1) Use a standardized form. ... 2) Document formal and informal teaching. ... 3) Describe the response of the learners. ... 4) When possible, put copies of educational materials in the chart. ... 5) Update the teaching plan.

Who should document all entries in a journal?

1. All entries should be documented and signed by the author.

How long does it take to complete a discharge summary?

The discharge summary must be completed within 35 days of discharge.

What documents does Sally Jones organize?

Sally Jones assembles a patient record and organizes the following documents into a separate section of the record: face sheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered

Who must sign an attestation statement?

The attending physician must sign an attestation statement.

Does Sunny Valley Hospital have patient record guidelines?

Sunny Valley Hospital has adopted the following as part of its patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices.

What documents does Sally Jones organize?

Sally Jones assembles the patient record and organizes the following documents into a separate section of the record: facesheet, advance directives, informed consent, patient property form, and death certificate. This separate section of the record would be considered:

What is the Joint Commission standard for consent to treatment?

The Joint Commission Standards requires a patient's consent to treatment and that the record contain evidence of consent. TRUE. A consent to admission documents the patient's consent for all medical treatment including procedures and surgeries to be completed during the current admission. FALSE.

Do all patient records have to be dated?

The Uniform Rules of Evidence states that for a record to be admissible in court of law, all patient record entries must be dated and timed.

Do you complete only necessary entries on preprinted forms?

Complete only necessary entries on preprinted forms. And if other patients are referenced in the record, document their names

Does Sunny Valley Hospital have patient record guidelines?

Sunny Valley hospital has adopted the following as part of its patient record documentation guidelines. Determine which guidelines need to be revised because they do not reflect sound documentation practices

What is pathology report?

The pathology report assists in the diagnosis and treatment of patients by documenting analysis of tissue removed surgically

When can discharge progress notes be documented?

A discharge progress note can be documented in the patient record instead of the discharge summary if the patient had an uncomplicated hospital stay of less than 48 hours

What is an admitting diagnosis?

The admitting diagnosis is the condition or disease for which the patient is seeking treatment.

What is the history of the present illness?

The history of the present illness is the patient's description of their current medical condition in their own words

How long does it take to get a death certificate?

The death certificate is usually filed with state Department of Health office of vital statistics within five days

How long does it take to file an ancillary report?

All ancillary reports should be filed in the patient's record within 24 hours after interpretation of test results

What is a complication in medical terms?

A complication is a pre-existing condition that will cause an increase in the patient's length of stay by at least one day

Who should document entries in a journal?

1.All entries should be documented and signed by the author.

When did the Patient Self-Determination Act of 1990 require all health care facilities to notify patients?

The Patient Self-Determination Act of 1990 requires all health care facilities to notify patients age 21 and over that they have the right to have an advance directive.

Why are records retrieved?

Describe the reasons records are retrieved. Records are retrieved for inpatient readmission (for nursing units), scheduled and unscheduled outpatient clinic visits (for clinics such as dermatology, orthopedics, and so on), authorized quality management studies, and education and research.

What is the unit number for Hillcrest Hospital?

Hillcrest Hospital uses a unit numbering system. Patient Tom Jones, admitted on January 4, was assigned patient record number 456789. Patient Mary Black, the next patient admitted, had a previous admission to the facility and at that time was assigned patient number 422223. On this admission, Mary should be assigned record number:

How long does it take to complete a H&P?

The record is not in compliance, as the H&P needs to be completed within 24 hours.

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.

Where is third party payer information obtained?

Third-party payer information is classified as financial data, and it is obtained from the patient at admission.

What is pathology report?

26. The pathology report assists in the diagnosis and treatment of patients by documenting analysis of tissue removed surgically.

What is the diagnosis of admitting a patient?

4. The admitting diagnosis is the condition or disease for which the patient is seeking treatment.

What is the Health Care Financing Administration now called?

9. The Health Care Financing Administration is now called the Centers for Medicare and Medicaid Services.

What is the history of the present illness?

20. The history of the present illness is the patient's own description of his or her current medical condition.

What is clinical data?

18. Clinical data contains all health care information obtained about a patient's care and treatment.

How long does it take to get a death certificate?

40. The death certificate is usually filed with a state department of health's office of vital statistics within five days.

What is a complication in medical terms?

6. A complication is a preexisting condition that will cause an increase in the patient's length of stay by at least one day.