Learning Goal: I’m working on a writing question and need an explanation and answer to help me learn.
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.
- List your citation(s) below the table and include page numbers when citing a book.
Requirements: