Components of Acute Care Health Record
Accreditation Organizations
Document Standards
Consents & Authorizations
Specialized Health Record Documentation
100
Documents demographic information about the patient.
What is registration record?
100
Has standards and accredits a number of healthcare settings and has earned CMS deemed status.
What is the Joint Commission?
100
Documents the patient's medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided.
What is clinical data?
100
Allows the healthcare facility to verbally disclose or send health information to other health organizations.
What is authorization to disclose information?
100
Records of infants, children, and adolescents requiring special content.
What is pediatric care documentation?
200
Documents opinions about a patient's condition furnished by providers other than the attending physician.
What is consultation report?
200
Accredits managed care organizations and focuses on patient safety, confidentiality, consumer protection, access to services, service quality and continuous improvement efforts.
What is the National Committee for Quality Assurance (NCQA)?
200
Includes demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information.
What is administrative data?
200
Written document that provides directions about a patient's desires in relation to care decisions for use by healthcare workers if the patient is incapacitated or not capable.
What is advance directive?
200
Standardized patient assessment instrument that is a component of the comprehensive assessment that is the foundation for the plan of care and Medicare reimbursement services for home healthcare.
What is Outcomes and Assessment Information Set (OASIS)?
300
Documents the patient's current and past health status.
What is medical history?
300
Oversees the Healthcare Facilities Accreditation Program (HFAP) which has Medicare deemed status for its hospital, critical access hospital, and ambulatory surgery center programs.
What is the American Osteopathic Association (AOA)?
300
Met through government entities such as the state or county in which they are located and must maintain as long as care is provided.
What is licensure requirements?
300
Requires healthcare facilities to provide written information on the patient's right to execute advance directives and to accept or refuse medical treatment.
What is the Patient Self-Determination Act (PSDA)?
300
Type of care that focuses on symptom management and patient comfort over life-prolonging measures.
What is palliative care?
400
Describes procedures performed and gives the names of clinicians and other providers; include the findings of x-rays, mammograms, ultrasounds, scans, lab tests, and other diagnostic procedures.
What is reports of diagnostic and therapeutic procedures?
400
Accredits rehabilitation programs and services in various rehabilitative settings.
What is the Commission on Accreditation of Rehabilitation Facilities (CARF)?
400
End result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization.
What is accreditation standards?
400
Requires providers with a direct treatment relationship with a patient to secure the patient's written acknowledgment that he or she received the provider's notice of privacy practices.
What is the Privacy Rule?
400
Special documentation requirements include psychiatric history, admitting psychiatric diagnoses, and multidisciplinary progress notes.
What is behavioral healthcare documentation?
500
Provides a chronological summary of the patient's illness and treatment as documented by physicians, nurses, and allied health professionals.
What is clinical observations?
500
Has established ambulatory care core standards for all organizations and adjunct standards that only pertain to specific types of services.
What is the Accreditation Association for Ambulatory Health Care (AAAHC)?
500
When government reimbursement standards that are applied to facilities that choose to participate in federal programs are met.
What is certification standards?
500
Obtained from patients or their legal representatives before providing care or services except in emergency situations.
What is consent to treatment?
500
For this type of care, documentation of a care plan review is required every 30 days.
What is hospice care documentation?
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