lab assignment 4 3 flow of patient information

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HIMT 1100 - Intro to HIMT Chapter 4 Homework(1)

Health information management technology (himt 1100), southern regional technical college.

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HIMT 1100 Introduction to Health Information Management Technology Chapter 4 Health care facilities are responsible for ensuring that health care services rendered to patients are documented according to federal and state regulations, as well as accrediting organizations, professional practice, and legal standards. Refer to Provider Responsibilities in chapter 4 of your textbook (Introduction to the Patient Record). Complete the following chart to summarize key concepts associated with provider documentation responsibilities. Do not copy and paste anything. This entire assignment must be in your own words. Points will be deducted for structure errors as per the grading rubric. Provider Documentation Guidelines Provider Documentation Summary of Key Concepts Responsibilities are required all patient entries. entries must be signed the Authentication of patient record verifying that it is entries accurate. require acceptable medical records: written signatures, Counter signatures, Initials, ETC. Abbreviations used in the patient record Legibility of patient record entries Timeliness of patient record entries includes medical staffed approved abbreviations. examples: Body Mass Index Discontinue or Discharge require all entries to be legible. If illegible, payers may deny payment. should be documented as soon as possible should complete physical examination to be performed no more than 30 days prior to admission or within 24 hours after admission is correcting documentation in Amending the patient record the patient record are only corrected Author requires a single line drawn between incorrect info. Date, time, and sign corrected The inpatient record contains various documents that are completed specific hospital personnel and care providers. It is important that health information management technology students understand, and can illustrate, the flow of patient information from admission to discharge, as well as decide the individuals responsible for completion of the documents. The chart below contains the flow of information in the inpatient record from the time of admission to discharge. Determine the hospital staff member (i. E. nurse) or physician (i. attending physician) responsible for completing the documentation listed. Flow of Patient Information Flow of Documentation Responsible Staff Member or Physician Staff Face Sheet Staff Admission Consent Staff Nursing Assessment Physician Physician Orders Physician Admission History and Physical Physician Laboratory Test Results Physician Operative Note Physician Physical Therapy Exam and Treatment

• Multiple Choice

Course : Health Information Management Technology (HIMT 1100)

University : southern regional technical college.

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