Transcription of Chapter 3 Content and Structure of the Health Record
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Chapter 3 Content and Structure of the Health Record
Learning Objectives To understand the Content of Health records in various healthcare settings To recognize the documentation requirements of accreditation organizations and state and federal government agencies To describe the different formats used for Health records in healthcare organizations To understand the advantages of electronic Health records over paper-based and hybrid Health recordsKey TermsAccreditationAccreditation Association for Ambulatory Health Care (AAAHC)Advance directiveAmerican Osteopathic Association (AOA)Anesthesia reportAuthorization to disclose informationAutopsy reportCare planCertificationCommission on Accreditation of Rehabilitation Facilities (CARF)Computer-based patient Record (CPR)Conditions for CoverageConditions of ParticipationConsent to treatmentConsultation reportChapter 3 Content and Structure of the Health RecordBonnie J. Petterson, PhD, RHIA47 Copyright 2007 by the American Health Information Management Association.
Discharge record analysis (reviewing the record upon patient discharge for missing elements) is done by health information personnel using a computer. The system filters documents so that only those needing review are accessed. Electronic signatures are used and physicians can enter the system at any of the Arizona Mayo sites. E-mail notices to
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