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 St
• Patient’s discharge summary • Final instructions to the patient upon discharge Medical History A complete medical history documents the patient’s current complaints and symptoms and lists his or her past medical, personal, and family history. In acute care, the medical history is usually the responsibility of the attending physician.
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