Using the template, complete the table for each administrative and clinical data item

Description

4-1 Administrative and Clinical Data

Using the template, complete the table for each administrative and clinical data item.

The element types are demographic, socioeconomic, financial, or clinical

Use page 81 in your textbook for assistance and include the page number in your citation below the table.

4-2 Provider Documentation Guidelines
Refer to the Provider Responsibilities section of Chapter 4 in your textbook starting on page 85.
Using the template, complete the table by summarizing each section of the chapter.

Each section that needs to be summarized is bold and in copper-colored font.

Write in complete sentences and include a citation below the table. Make sure the page range from the textbook is included in the citation.

4-3 Flow of Patient Information

Refer to the Inpatient Record: Admission to Discharge section of Chapter 4 in your textbook starting on page 94.

Using the template, list the individual responsible for documenting each item.

Please note, your answers will not always be “nurse” or “physician” as demonstrated in the lab manual. The responsible member should be specific to the documentation item. Watch the video for help.

Include a citation below the table with the page number(s) from the textbook.

4-4 Medicare Conditions of Participation
Read the Conditions of Participation: Medical Record Services in your lab manual.

For each of the 3 sections, interpret the information.

Write in complete sentences

Pretend you are explaining it to someone who is outside of the healthcare field.

There is no citation or reference required for this portion. Never cite or list your lab manual as a source on your Reference page.

4-5 Amending the Patient Record

Review the section Amending the Patient Record from Chapter 4 in your textbook starting on page 88.
Using the template, complete the table and identify if the amendment was correctly documented and justify why or why not.
You may also review the following Practice Brief from AHIMA for further information and additional citation/reference.

Patient Access and Amendment to Health RecordsLinks to an external site.

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Chapter 4 Lab Assignments
Student Name
HIM1000C: Introduction to Health Information Management
Kacey Bishop
Due Date
2
Lab Assignment 4-1 Administrative and Clinical Data
Administrative and Clinical Data Item
Type of Element
Patient name
Demographic
Patient address
Demographic
Telephone
Gender
Date of birth
Patient number
Admission date and time
Primary insurance plan
Financial
Primary insurance plan ID#
Secondary insurance plan
Secondary insurance plan ID#
Occupation
Name of employer
Medication allergies/reactions
Current medications
BP, P, R, T, WT (vital signs)
Chief complaint (CC)
Past medical history (PMH)
Note
Clinical
3
Lab Assignment 4-2 Provider Documentation Guidelines
Provider Documentation Responsibilities
Authentication of patient record entries
Abbreviations used in the patient record
Legibility of patient record entries
Timeliness of patient record entries
Amending the patient record
Summary of Key Concepts
4
Lab Assignment 4-3 Flow of Patient Information
Flow of Documentation
Face sheet
Admission consent
Nursing assessment
Physician orders
Admission history and physical
Laboratory test results
Operative note/report
Physical therapy exam and treatment
Discharge instructions
Discharge summary
Responsible Staff Member or Physician
5
Lab Assignment 4-4 Medicare Conditions of Participation
Condition
(a) Standard: Organization and staffing
(b) Standard: Form and retention of
record
(c) Standard: Content of record
Interpretation
6
Lab Assignment 4-5 Amending the Patient Record
Case
Correctly
Number Documented?
1
2
3
4
5
6
7
8
9
10
Justification

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