1. Documentation the recording of pertinent health care findings, interventions,
responses
to treatment as a business record and form of communication
among caregivers
2. Documentation Progress notes, lab test results, radiology imaging reports,
exam- ples operative re- ports (complete medical picture of the patient)
3. Health record a patients health care visit and treatment history historical value
cen- tralizes
documenta- tion
regarding
Appropriate, accurate, reliable, readily accesible
4. A document its
self needs to be
(in HR)
5. Data quality the reliability and ettectivness of data for its intended uses in
operation, decision maing and planning.
6. reimbursement also applies to biling claims, admin business disease registry
date/
7. must meet accuracy, reliability, ettectiveness.
accreda- tion req
8. Poor assessment evaluation of= impacts billing, reimbursement,
documentation claims
impacts
9. standard set of priciples, codes, beliefs, guidelines, regulations, that have
been
vetted and agreed upon by an individual (authroity)
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, AHIMA Practice Review for Exam 4 Questions & Answers.
10. standard principles foundation for system
codes= moral conduct beliefs=view point guidelines=rules
eevryone must follow regulations to prevent harm
11. docu standards 5 principles, codes, belief, regulations that guide hr docu
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