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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.

Mayo Clinic Hospital, a 205-bed acute care hospital located in Phoenix, Arizona, has close to 350 physicians from more than 65 medical and surgical specialties on its medical staff. The Phoenix hospital opened in the fall of 1998 with a hybrid health record.

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  Health, Record, Content, Structure, Clinic, Mayo, Mayo clinic, Content and structure of the health record

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