AHIMA Documentation Standards Ch. 4

<p>Compliance with medical staff bylaws</p> Signup and view all the answers

<p>The Joint Commission</p> Signup and view all the answers

<p>Hospitals, ambulatory healthcare, and behavioral health</p> Signup and view all the answers

<p>To define the legal health record</p> Signup and view all the answers

<p>To respond to legally permissible requests for patient information</p> Signup and view all the answers

<p>Only the authorized individuals specified in the organization's policies</p> Signup and view all the answers

<p>Enhances the organization's reputation in the eyes of patients</p> Signup and view all the answers

<p>To communicate among caregivers</p> Signup and view all the answers

<p>Poor outcomes</p> Signup and view all the answers

<p>How healthcare providers should document treatment and services</p> Signup and view all the answers

<p>Principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation</p> Signup and view all the answers

<p>Clear and specific documentation standards</p> Signup and view all the answers

<p>Who may receive and transcribe verbal physician’s orders</p> Signup and view all the answers

<p>At the time the services they describe are rendered</p> Signup and view all the answers

<p>Only approved abbreviations and symbols</p> Signup and view all the answers

<p>Legible, complete, dated, timed, and authenticated</p> Signup and view all the answers

<p>Controls to prevent any changes from being made</p> Signup and view all the answers

<p>Clinical and administrative data</p> Signup and view all the answers

<p>Labor and delivery information.</p> Signup and view all the answers

<p>Preventive care.</p> Signup and view all the answers