HIM 200: Final Project
HIM 200 Final Project
Teishalyn Erkard-Intravichit
Intro to Health Information Tech
Instructor Ramonica Pace
Southern New Hampshire University
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The patient's family history has no known instances of diabetes. This information
was recorded in the History and Physical Exam portion of the patient record. The patient had an
extraction of six mandibular teeth and mandibular alveolectomy performed by Dr. Harold Dunn;
with the use of General and Xylocaine infiltration anesthetic. The patient was prescribed Tylenol
with Codeine and Tylenol #2 as needed per the Medication Administration Record. [ CITATION
Gre \l 1033 ]
Standards of Record of Care (RC) are routinely reviewed by the joint commission
to make sure that all required information is documented in the patient record accurately. The
Joint Commission states that all hospitals must maintain complete and accurate patient medical
records. All entries into that record must also be authenticated and entered accurately and
promptly. The commission checks to see if hospitals are conducting ongoing evaluations of their
records and if original or legally reproduced forms of health records are retained by the hospital
location. All patient records must contain information that reflects the patient's care, treatment.
services, documentation on operative or high-risk procedures, and the use of moderate/deep
sedation or anesthesia. Standards state that all qualified medical staff authorized to receive, and
record verbal orders must not only be identified but confirmed as the only persons receiving and
recording orders. The patient record must also contain discharge information, including a
summary of the patient's stay, treatment, and all medications administered. [ CITATION
The21 \l 1033 ]
In this patient's health record, some sections were not complete and missing
necessary documentation, thereby destroying patient record continuity. On the Inpatient Face
Sheet, the Diagnoses and Procedures are listed, but the ICD Codes have been omitted. The
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Discharge Instructions are not noted, and the Attending Physician Authentication is also missing.
The Consent to Release Information for Reimbursement Purposes section has not been
completed by either the patient or witness. The wrong patient's name is listed in the Advance
Directive section and the patient initials to the answered questions are also missing. In the
section involving the distribution of Patient Right information, the first question has not been
answered indicating the questions were answered or if actions were taken that were required.
The line indicating that the information was given to someone other than family is checked, but
there is no explanation following giving the reason this was done and the name of the person the
information was given to, and their relationship to the patient. It is also indicated in this section
that the information was given in a language other than English, but there is no specification of
the language or the method it was delivered in. The signature indicates that the patient received
this information, but the above verifications are not clear. The Discharge Summary is missing
the Physician'