Clinical Documentation (Chapter 1) Updated.

Clinical Documentation (Chapter 1) UThe primary means of communication between members of the health-care team that facilitates continuity of care and communication among the professionals involved in a patient's care. - answerMedical Record The most important legal functions of medical records are to: - answerProvide evidence that appropriate care was given and to document the patient's response to that care. Who is the primary audience of medical records? - answerOther medical professionals involved in direct pt care. The Centers for Medicare and Medicaid Services (CMS) is one agency of the: - answerU.S. Department of Health and Human Services (HHS) Who established the specific guidelines for documentation? - answerCenters for Medicare and Medicaid Services (CMS) What are the two sets of documentation guidelines currently being used? - answerThe 1995 and the 1997 guidelines There are minor differences between the two guidelines, and it is recommended that health-care providers refer to the _____ guidelines to identify those differences. - answer1995 What should the documentation of each patient encounter include? - answer• Reason for the encounter and relevant history, physical examination findings, and diagnostic test results • Assessment, clinical impression, or dx • Plan for care • Date and legible identity of the observer Each entry should include what? - answerThe date and time the record was created and should identify the person creating the record. What guidelines should be used when making a correction on a medical record? - answerYou should draw a single line through the text that is erroneous, initial and date the entry, and label it as an error. (T/F) You should stamp a record "signed but not read" when seeing patients so charting at the end of the day becomes more efficient. - answerFalse. pdated.