Documentation Standards
A voluntary process of institutional or organizational review in which quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against pre-established written criteria.
What is accreditation?
The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services.
What is clinical data?
A method used to construct physician progress notes and the acronym is a technique physicians use to remember what elements of documentation must be included within a progress note.
What is subjective, objective, assessment, plan (SOAP)?
The administrative and operational guidelines under which facilities are allowed to take part in the Medicare and Medicaid programs.
What are Conditions of Participation (CoPs)?
The comments of physicians, nurses, and other caregivers in order to create a chronological report of the patient's condition and response to treatment during his/her hospital stay.
What are clinical observations?
The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end user.
What is document imaging?
The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements.
What is certification?
The instructions the physician gives to other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient.
What are physician orders?
Health record in which the documentation contained within is organized by source or originating department.
What is a source-orientated health record?
Practices that either directly or indirectly result in unnecessary costs to the Medicare Program.
What is abuse?
Documents that the patient or the patient's authorized representative sign, confirming the receipt of important and applicable information.
What are acknowledgements?
This health record consists of a problem list, the history and physical examination and initial lab findings, the initial plan, and progress notes.
What is the problem-oriented health record?
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation.
What is deemed status?
This note includes the post-anesthesia note, nurses' notes regarding the patient's condition and surgical site, vital signs, intravenous fluids, and other medical monitoring.
What is the recovery room report?
When the health record post patient discharge is kept in reverse chronological order.
What is the universal chart order?