HEALTH RECORD CONTENT AND
DOCUMENTATION
health record documentation standard bearers - Answers-1. American College of
Surgeons
2. Joint Commission
3. Medicare Conditions of Participation (CoP)
4. State licensure requirements
5. Internal organizational standards
functions of the health record - Answers-1. Ongoing care and treatment of individual
patients
2. Clinical decision making and communication
3. Reimbursement
4. Evaluation of the quality and efficacy of care
5. Medical research and education
6. Operational management
7. Legal purposes
healthcare organization - Answers-Who does the physical health record belong to?
patient - Answers-Who does the information contained in the health record belong to?
administrative and demographic information - Answers-Registration data, including the
admission record and face sheet; consent to treatment; consent to special procedures;
consent to use or disclose protected health record information, including the Notice of
Privacy Practices; advance directives and Durable Power of Attorney;
acknowledgement of patient's rights information, including the Patient Bill of Rights
clinical data - Answers-1. Medical history and physical examination (H&P)
2. Diagnostic and therapeutic orders
3. Clinical observations
4. Conclusions at the termination of care, including the discharge summary
medical history - Answers-A summary of the patient's illness from his or her point of
view
components of a medical history - Answers-1. Chief complaint
2. Present illness or history of present illness
3. Past medical history
4. Social and personal history
5. Family medical history
6. Review of systems
, review of systems - Answers-A subjective run-down of the body systems designed to
determine any symptom contributing to or related to the chief complaint
physical exam - Answers-An objective and hands-on assessment of the patient by the
provider to determine or confirm that patients complaints and/or diagnosis
CMS H&P timeline - Answers-1. Must be completed and in the record within 24 hours of
admission
2. Can be completed no more than 30 days before admission
3. If it is completed within the 30 days prior to admission, an interval history must be
conducted and entered into the record within 24 hours in order to document any
changes in the patient's condition
Joint Commission H&P requirements - Answers-1. Must be recorded and in the record
prior to any operative procedure
2. When the physician chooses to dictate the H&P, the report must be transcribed and
in the record before the procedure
3. When the report is dictated but not transcribed, a written preoperative not covering
the H&P is acceptable only in emergency and the physician must write an explanation
of the emergency circumstances
diagnostic and therapeutic orders - Answers-Physician orders, verbal orders, do not
resuscitate orders (DNR), and discharge orders
physician orders - Answers-Instructions that direct the healthcare team in areas such as
treatment, ancillary medical services, laboratory tests, radiological procedures,
medications, devices and related materials, restraints, and seclusion
do not resuscitate orders (DNR) - Answers-Must contain documentation that the
decision to withhold CPR was discussed, when the decision was made, and who
participated in the decision
discharge orders - Answers-Can only be issued by the physician once a patient leaves
the hospital
clinical observations or notes - Answers-Progress notes, consultations, nursing
services, nursing care plan, care paths, ancillary services, and surgical services
progress notes - Answers-Chronological statements about the patient's response to
treatment during his or her stay in the facility
consultations - Answers-The opinions of specialists that include both that the
examination occurred and that the requesting physician reviewed the report
nursing services - Answers-Notes that coordinate the patient's care to ensure that
orders are carried out
DOCUMENTATION
health record documentation standard bearers - Answers-1. American College of
Surgeons
2. Joint Commission
3. Medicare Conditions of Participation (CoP)
4. State licensure requirements
5. Internal organizational standards
functions of the health record - Answers-1. Ongoing care and treatment of individual
patients
2. Clinical decision making and communication
3. Reimbursement
4. Evaluation of the quality and efficacy of care
5. Medical research and education
6. Operational management
7. Legal purposes
healthcare organization - Answers-Who does the physical health record belong to?
patient - Answers-Who does the information contained in the health record belong to?
administrative and demographic information - Answers-Registration data, including the
admission record and face sheet; consent to treatment; consent to special procedures;
consent to use or disclose protected health record information, including the Notice of
Privacy Practices; advance directives and Durable Power of Attorney;
acknowledgement of patient's rights information, including the Patient Bill of Rights
clinical data - Answers-1. Medical history and physical examination (H&P)
2. Diagnostic and therapeutic orders
3. Clinical observations
4. Conclusions at the termination of care, including the discharge summary
medical history - Answers-A summary of the patient's illness from his or her point of
view
components of a medical history - Answers-1. Chief complaint
2. Present illness or history of present illness
3. Past medical history
4. Social and personal history
5. Family medical history
6. Review of systems
, review of systems - Answers-A subjective run-down of the body systems designed to
determine any symptom contributing to or related to the chief complaint
physical exam - Answers-An objective and hands-on assessment of the patient by the
provider to determine or confirm that patients complaints and/or diagnosis
CMS H&P timeline - Answers-1. Must be completed and in the record within 24 hours of
admission
2. Can be completed no more than 30 days before admission
3. If it is completed within the 30 days prior to admission, an interval history must be
conducted and entered into the record within 24 hours in order to document any
changes in the patient's condition
Joint Commission H&P requirements - Answers-1. Must be recorded and in the record
prior to any operative procedure
2. When the physician chooses to dictate the H&P, the report must be transcribed and
in the record before the procedure
3. When the report is dictated but not transcribed, a written preoperative not covering
the H&P is acceptable only in emergency and the physician must write an explanation
of the emergency circumstances
diagnostic and therapeutic orders - Answers-Physician orders, verbal orders, do not
resuscitate orders (DNR), and discharge orders
physician orders - Answers-Instructions that direct the healthcare team in areas such as
treatment, ancillary medical services, laboratory tests, radiological procedures,
medications, devices and related materials, restraints, and seclusion
do not resuscitate orders (DNR) - Answers-Must contain documentation that the
decision to withhold CPR was discussed, when the decision was made, and who
participated in the decision
discharge orders - Answers-Can only be issued by the physician once a patient leaves
the hospital
clinical observations or notes - Answers-Progress notes, consultations, nursing
services, nursing care plan, care paths, ancillary services, and surgical services
progress notes - Answers-Chronological statements about the patient's response to
treatment during his or her stay in the facility
consultations - Answers-The opinions of specialists that include both that the
examination occurred and that the requesting physician reviewed the report
nursing services - Answers-Notes that coordinate the patient's care to ensure that
orders are carried out
