Documentation Standards Flashcards
Medical, legal, and administrative operations that minimize exposure to liability is referred to as?
Risk management
What organization accredits the majority of the U.S. Hospitals and other healthcare organizations?
The joint commission
Review of the medical record to identify potential medical errors resulting in personal injury.
Occurrence screening
When healthcare professionals use common medical terms to describe patient conditions and treatments, this is called ___.
Uniformity of consent
Ensure accuracy, uniformity, and legibility of medical record entries.
Documentation standards
Reviewing the medical record to ensure documentation standards are met.
Qualitative analysis
Medical record review for completeness
Quantitative analysis
Complete and legible medical record documentation
Acceptable documentation
Responsible for ensuring accurate and timely healthcare documentation
Health information management professional
Creation of common definitions of medical terms for documentation of the patients conditions in the medical record
Vocabulary standards
Misrepresentation of the documentation to receive reimbursement.
Fraud and abuse
Medical record documentation must be uniform, accurate, complete, ___, and timely.
Legible
Any correction added by the patient to the medical record need to be inserted as an ___.
Addendum
Only ___ and symbols approved by the organization may be used in the medical record.
Abbreviations
Documentation guidelines have been developed by various organizations to ensure patients receive ___ care.
Quality
Only individuals ___ by the organization’s policies should be allowed to document information in the medical record
Authorized
Every healthcare organization should be implement ___ to ensure the uniformity and content of the medical record
Policies
Medical record entries should be ___ at the time of service
Documented
A common documentation deficiency on medical reports is missing physician ___.
Signatures
Entries in the medical record should be ___
Permanent
When documentation problems are found in the patient’s medical record, a ___ slip should be created and placed in the record
Deficiency
Incomplete medical record documentation
Unacceptable documentation
