Content and Structure of the Health Record Crossword

Contains elements of both paper and electronic records
Review the record for missing documentation
Data documents patient's medical condition, diagnosis, and procedures
Data documents patient's demographic, financial, consent, and authorizations status
reference points against which structures, processes, or outcomes can be measured
guidelines which govern the practice of employees within a specific organization
government reimbursement program standards
Medicare recognized Accreditation Organization
international accrediting organization
focuses on accreditation of managed care organizations
Signatures are attached via an _______ process in electronic systems
these notes serve to justify further acute care treatment in the facility
summary of the patient's problems with a detailed plan for interventions
The consent a patient gives after an explanation and an opportunity to ask questions
consent where a patient voluntarily submits to treatment
this report describes the surgical procedures performed on a patient
this report documents the clinical opinion of a physician other than the primary or attending
another name for referral form
the study of the statistical characteristics of human populations
requires healthcare facilities to provide written information on the patient's right to execute advance directives
long term care plan format based on mds
this document indicates current and past medical conditions
questions for practitioners generated from record reviews
this sets professional values, principles, and guidelines