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19 Cards in this Set
- Front
- Back
The hospital maintains complete and accurate...
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...medical records for each individual patient.
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Entries in the medical record are...
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...authenticated.
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Documentation in the medical record...
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...is entered in a timely manner.
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The hospital audits...
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...its medical records.
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The medical record contains information that reflects...
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...the patient's care, treatment, and services.
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The hospital retains...
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...its medical records.
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The patient’s medical record documents operative or other high-risk procedures and...
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...the use of moderate or deep sedation or
anesthesia. |
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For hospitals that do not use accreditation for deemed status purposes: The medical record contains documentation of the use...
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...of restraint and/or seclusion.
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The medical record contains a summary list for each patient who receives continuing...
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...ambulatory care services.
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Qualified staff receive and record...
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...verbal orders.
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The hospital documents the patient’s discharge...
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...information.
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The hospital plans for...
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...managing information.
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The hospital plans for continuity of its...
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...information management processes.
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The hospital protects the...
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...privacy of health information.
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The hospital maintains the security and...
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...integrity of health information.
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The hospital effectively manages the...
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...collection of health information
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The hospital retrieves, disseminates, and transmits...
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...health information in useful formats.
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Knowledge-based information resources are...
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...available, current, and authoritative.
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The hospital maintains...
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...accurate health information.
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