completeness, adequacy, and quality of documentation. adverse effects and contraindications of drugs utilized during hospitalization.ĭ. quality of care through the use of pre-established criteria.ī. The performance of qualitative analysis is an important tool in ensuring data quality. Codes are usually recorded on a different form in the record. The attending physician records the discharge summary. Some reference to the patient's history may be found in the discharge summary, but not a detailed history. correct codes for significant procedures.
significant findings during hospitalization.ĭ. a note from social services or discharge planning.Ĭ. Fingerprint signatures are individualized automatically Discharge summary documentation must include:ī. Similarly, in a computer-based system, it is important to ensure that personal identification codes used to authenticate entries are used only by the persons to whom they are assigned. In a completely computerized patient record system, similar measures might be utilized to govern the use of: electronic signatures Authentication by signature stamps requires a written agreement with the facility not to delegate the use of the stamps. The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp.
The statute of limitations for each state is information that is crucial in determining record retention schedules. The minimum length of time for retaining original medical records is primarily governed by: state law. Only house staff members who are under the supervision of active staff members require countersignatures once the privilege has been granted.
Those who make entries in the medical record are given that privilege by the medical staff. Joint Commission requires the attending physician to countersign health record documentation that is entered by: interns or medical students.
0 kommentar(er)
