written signatures, countersignatures, biometrics, pin numbers
What is authentication
200
completed on admission to the hospital and contains both the patient's and physician's information of the patient's illness, must be completed within 24 hours of admission
What is the history and physical exam
300
mandatory for all health care organizations
What is licensure
300
nursing home, skilled nursing facility, residential care, continuing care retirement
What is long term care
300
document collecting information on potentially compensable events and cannot be filed in the medical record
What is the incident report
300
medical record incomplete over 30 days
What is a delinquent record
300
documents any specimens removed during surgery
What is the operative report
400
CMS standards
what is Conditions of Participation
400
chemotherapy, drug therapy, hydration therapy
what is home infusion care
400
chart order with the newest information at the beginning
what is reverse chronological order
400
draw a single line, date, time, initial, enter correct information
What is correcting a chart entry
400
a pre-existing condition that is sometimes a secondary diagnosis
What is a comorbidity
500
lab department, radiology department,
What is diagnostic care
500
provides a system of health surveillance to monitor and prevent outbreak of diseases
What is the CDC
500
database, problem list, initial plan, progress notes
what is problem oriented record
500
nursing notes, physician notes, lab reports, radiology reports are filed together by where document was generated
What is source oriented record
500
condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital