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 Coverag
Patient assessment instrument (PAI) Patient history questionnaire Patient Self-Determination Act (PSDA) Patient’s bill of rights Personal health record (PHR) Physical examination report Physician’s orders Problem list Problem-oriented health records Progress notes Recovery room report Resident assessment instrument (RAI) Resident assessment ...
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