Documentation Requirements for the Acute Care Inpatient Record Essay Example for Free

Documentation Requirements for the Acute Care Inpatient bring down EssayThe medical record is a tool for collecting, storing, and processing patient in initializeion. Records are being utilise daily for a multitude of purposes, including providing a means of communication between the medical student and the other members of the healthcare team caring for the patient providing a basis for evaluating the adequacy and appropriateness of care providing data to incarnate insurance claims protecting the legal interests of the patient, the facility, and the physician providing clinical data for research and education ?General Guidelines for tolerant Record Documentation ? Each hospital should have policies that ensure uniformity of both content and format of the patient record based on all applicable accreditation standards, federal and state regulations, payer requirements, and professional practice standards. ? The patient record should be organized systematically to facilita te data retrieval and compilation. ? except soulfulnesss authorized by the hospitals policies to document in the patient record should do so.This data should be recorded in the medical staff rules and regulations and/or the hospitals administrative policies. ? hospital policy and/or medical staff rules and regulations should specify who may receive and transcribe a physicians verbal orders. ? Patient record entries should be documented at the time the treatment they get word is rendered. ? Authors of all entries should be clearly identifiable. ? Abbreviations and symbols in the patient record are permitted only when approved fit to hospital and medical staff bylaws, rules, and regulations.All entries in the patient records should be permanent. Errors should be corrected as follows draw a single line in ink through the incorrect entry, and print actus reus at the top of the entry with a legal signature or initials, date, time, title, reason for change, and discipline of the p erson making the correction. Errors must never be obliterated. The existing entry should be left intact with department of corrections entered in chronological order. Late entries should be labeled as such. ? In the event the patient wishes to reanimate information in the record, it shall be done as an addendum, without change to the original entry, and shall be clearly determine as an additional document appended to he original patient record at the direction of the patient, who depart thereafter bear responsibility for the explaining the change.The health information department should develop, implement, and evaluate policies and procedures related to quantitative and qualitative analysis of patient records. ? Review any requirements outlined in state law, regulation, or healthcare facility licensure standards as they relate to documentation requirements. If your state requires that verbal orders be authenticated within a stipulate time frame, accrediting and licensing agencies will survey for compliance with that requirement.