Course/Assessment Code: D255 Task 1
Student Name: Oliver R Martinez
Student ID: 013350240
Date: May 19, 2026
A. Explain how different departments within a hospital could work both
independently and collaboratively to ensure all elements of the
“Record of Care, Treatment, and Services (RC)” standard from the
Joint Commission quality improvement and accreditation standards
are met (Hospital Accreditation Program, 2025).
When providing patient care, a hospital works like a well-organized
system. Each department plays a role in patient care. Nurses, for
example, document a patient's vital signs, medications, and patient
care updates. Laboratory staff also play a role; they process test
results and report important findings. By using an Electronic Health
Record (EHR) system, departments can share and document
information for the entire healthcare team. By using an EHR system, a
healthcare team can improve patient care, enhance communication
between departments, and maintain consistent documentation
procedures throughout the hospital. By maintaining these practices,
they can also meet the Joint Commission’s Record of Care, Treatment,
and Services standards.
If an EHR system is used, it allows specialists, such as a Clinical
Documentation Specialist, to review records to ensure they are
accurate and complete. Each department has its own functions, but
they work together to ensure that patient care is standard throughout
the hospital. They make sure all forms are completed as needed.
1. Laboratory Department – Makes sure patient information is
entered into the system promptly. This ensures the patient can
receive the treatment they need quickly. They also communicate
results to providers.
2. Nursing Department – Takes record of what medication a
patient takes and records a patient's vitals. They also update the
care plan and information about a patient’s condition.
3. Health Information Management (HIM) Department – They will
review the patient data to ensure it adheres to healthcare
regulations and accreditation standards. They also ensure all
, information is entered completely. This department also ensures
that all required forms are available in the patient's chart.
B. Explain why a patient’s medical record is considered an integral part
of the Joint Commission’s tracer methodology for quality improvement
and accreditation standards.
A patient’s medical record is considered an integral part of the
healthcare journey. It can help both the patient and the
healthcare providers by keeping detailed documentation of the
care received. Medical records also support the methodology by
documenting a patient's care across several departments, from
the beginning of their care (Hospital Accreditation Program,
2025). This can help hospitals provide better care by identifying
problems with safety, the quality of care, or even compliance
standards.
C. Discuss why the Centers for Medicare and Medicaid Services (CMS)
utilizes the Uniform Hospital Discharge Data Set (UHDDS).
There is a large variety of medical facilities, and each one
provides a different level of patient care. Because there are so
many facilities, it is important to have a standardized way to
collect patient information. The Centers for Medicare and
Medicaid Services (CMS) uses the Uniform Hospital Discharge
Data Set (UHDDS) to collect information from healthcare
facilities in the same way (Centers for Medicare and Medicaid
Services [CMS], n.d.). By using this system, CMS can track
reimbursement rates, quality of care, and healthcare trends
throughout facilities (CMS, n.d.). They also use the available
data to see opportunities for improvement.
D. Explain why the selection of the correct principal diagnosis is critical,
based on your knowledge of billing and reimbursement.
It is important to make sure that the correct principal diagnosis
is made because it affects what insurance pays a health provider
(CMS, n.d.). It is also important because different departments
will use the diagnosis in the EHR to guide patient care. If the
wrong diagnosis is added, a patient may be billed incorrectly.
This can also lead to coding compliance issues and cause issues
during an insurance audit. This could result in a healthcare
provider not being able to accept certain insurance providers in
the future.
At the dental office where I work, entering the correct diagnosis
code is imperative in obtaining the correct authorizations from
Student Name: Oliver R Martinez
Student ID: 013350240
Date: May 19, 2026
A. Explain how different departments within a hospital could work both
independently and collaboratively to ensure all elements of the
“Record of Care, Treatment, and Services (RC)” standard from the
Joint Commission quality improvement and accreditation standards
are met (Hospital Accreditation Program, 2025).
When providing patient care, a hospital works like a well-organized
system. Each department plays a role in patient care. Nurses, for
example, document a patient's vital signs, medications, and patient
care updates. Laboratory staff also play a role; they process test
results and report important findings. By using an Electronic Health
Record (EHR) system, departments can share and document
information for the entire healthcare team. By using an EHR system, a
healthcare team can improve patient care, enhance communication
between departments, and maintain consistent documentation
procedures throughout the hospital. By maintaining these practices,
they can also meet the Joint Commission’s Record of Care, Treatment,
and Services standards.
If an EHR system is used, it allows specialists, such as a Clinical
Documentation Specialist, to review records to ensure they are
accurate and complete. Each department has its own functions, but
they work together to ensure that patient care is standard throughout
the hospital. They make sure all forms are completed as needed.
1. Laboratory Department – Makes sure patient information is
entered into the system promptly. This ensures the patient can
receive the treatment they need quickly. They also communicate
results to providers.
2. Nursing Department – Takes record of what medication a
patient takes and records a patient's vitals. They also update the
care plan and information about a patient’s condition.
3. Health Information Management (HIM) Department – They will
review the patient data to ensure it adheres to healthcare
regulations and accreditation standards. They also ensure all
, information is entered completely. This department also ensures
that all required forms are available in the patient's chart.
B. Explain why a patient’s medical record is considered an integral part
of the Joint Commission’s tracer methodology for quality improvement
and accreditation standards.
A patient’s medical record is considered an integral part of the
healthcare journey. It can help both the patient and the
healthcare providers by keeping detailed documentation of the
care received. Medical records also support the methodology by
documenting a patient's care across several departments, from
the beginning of their care (Hospital Accreditation Program,
2025). This can help hospitals provide better care by identifying
problems with safety, the quality of care, or even compliance
standards.
C. Discuss why the Centers for Medicare and Medicaid Services (CMS)
utilizes the Uniform Hospital Discharge Data Set (UHDDS).
There is a large variety of medical facilities, and each one
provides a different level of patient care. Because there are so
many facilities, it is important to have a standardized way to
collect patient information. The Centers for Medicare and
Medicaid Services (CMS) uses the Uniform Hospital Discharge
Data Set (UHDDS) to collect information from healthcare
facilities in the same way (Centers for Medicare and Medicaid
Services [CMS], n.d.). By using this system, CMS can track
reimbursement rates, quality of care, and healthcare trends
throughout facilities (CMS, n.d.). They also use the available
data to see opportunities for improvement.
D. Explain why the selection of the correct principal diagnosis is critical,
based on your knowledge of billing and reimbursement.
It is important to make sure that the correct principal diagnosis
is made because it affects what insurance pays a health provider
(CMS, n.d.). It is also important because different departments
will use the diagnosis in the EHR to guide patient care. If the
wrong diagnosis is added, a patient may be billed incorrectly.
This can also lead to coding compliance issues and cause issues
during an insurance audit. This could result in a healthcare
provider not being able to accept certain insurance providers in
the future.
At the dental office where I work, entering the correct diagnosis
code is imperative in obtaining the correct authorizations from
