Joint Commission quarterly update: Medical record documentation guide and medical record reviews
HIM Briefings, April 1, 2016
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.
Our readers have been asking for an updated medical record documentation guide, and here it is?new and improved! The guide provides references to the associated CMS Conditions of Participation and new and revised standards and elements of performance (EP). A recent Joint Commission column discussed ongoing record reviews and the continued focus of Joint Commission surveyors related to documentation in the medical record. The guide takes the Record of Care, Treatment, and Services chapter and breaks it down into an easy-to-use tool for comprehensive record reviews by topic.
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.
Related Products
-
HIPAA Privacy and Security: Coders, Billers, and the HIM Staff
This course explains the HIPAA privacy and security rules that are relevant to coders, billers, and the HIM staff. It also...
-
HIPAA Privacy and Security for Nurses and Clinical Staff
This course explains the HIPAA privacy and security rules that are relevant to nurses and other clinical staff. It also...
-
HIPAA Privacy and Security: Registration and Front Office Staff
This course explains the HIPAA privacy and security rules as applicable and relevant to the registration and front office...
-
HIPAA Privacy and Security: Nutrition, Environmental Services, & Volunteer Staff
This course explains the HIPAA privacy and security rules as applicable and relevant to nutrition, environmental services...
-
HIPAA Privacy and Security: Business Associates
Most Popular
- Articles
-
- Don't forget the three checks in medication administration
- Diagnostic v. screening mammogram based on referring physician’s order
- Practice the six rights of medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Q&A: Primary, principal, and secondary diagnoses
- What to include on the incident report
- Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines
- What does case-mix index mean to you?
- OB services: Coding inside and outside of the package
- Neurological checks for head injuries
- E-mailed
-
- Coding Clinic reiterates guidelines for provider documentation
- Clinically Speaking: Check CDI efforts related to functional quadriplegia
- What does HIPAA say about faxing patient information?
- Sample questions for an infection control mock tracer
- Q&A: Why can’t we bill ventilator management in the ED?
- Q&A: How should we code fluoroscopy for outpatient procedures?
- Neurological checks for head injuries
- Know the medical gas cylinder storage requirements
- Know guidelines and subtle differences in code descriptions for laceration repairs
- Do residents need to be credentialed?
- Searched
