As you explain your rationale for a deficiency, please include the agency or organization that governs this area of documentation. Patient came in for elective procedure and in postop recovery they experienced a stroke. After the acute issue was resolved, patient was transferred to a detached facility for recovery. What type of summary should the physician be dictating? Explain your rationale. What agency or organization governs this area of documentation requirement? Mrs. Johnson was admitted as an inpatient to Rasmussen Hospital on September 16. Dr. Smith dictated a History and Physical report for Mrs. Johnson on September 20. Is Dr. Smith’s History and Physical report a deficiency? Explain your rationale. What agency or organization governs this area of documentation requirement? Dr. has just completed a cholecystectomy in the Operating Suite and has 15 minutes before his next patient arrives in surgery. What do standards require of the physician in regards to this procedure? Explain your rationale. What agency or organization governs this area of documentation requirement? Dr. Jefferson forgot to sign one of his progress entered in a patient chart. The patient was discharged 45 days ago. Is this patient’s health record deficient? Explain your rationale. What agency or organization governs this area of documentation requirement? Mrs. was re-admitted 28 days after discharge for same condition. Is it appropriate for the physician to use the same History and Physical from her first admission? Explain your rationale. What agency or organization governs this area of documentation requirement? Janet Kennedy vaginally delivered a healthy baby boy at Community Hospital.
As you explain your rationale for a deficiency, please include the agency or organization that governs this area of documentation. Patient came in for elective procedure and in postop recovery they experienced a stroke. After the acute issue was resolved, patient was transferred to a detached facility for recovery. What type of summary should the physician be dictating? Explain your rationale. What agency or organization governs this area of documentation requirement? Mrs. Johnson was admitted as an inpatient to Rasmussen Hospital on September 16. Dr. Smith dictated a History and Physical report for Mrs. Johnson on September 20. Is Dr. Smith’s History and Physical report a deficiency? Explain your rationale. What agency or organization governs this area of documentation requirement? Dr. has just completed a cholecystectomy in the Operating Suite and has 15 minutes before his next patient arrives in surgery. What do standards require of the physician in regards to this procedure? Explain your rationale. What agency or organization governs this area of documentation requirement? Dr. Jefferson forgot to sign one of his progress entered in a patient chart. The patient was discharged 45 days ago. Is this patient’s health record deficient? Explain your rationale. What agency or organization governs this area of documentation requirement? Mrs. was re-admitted 28 days after discharge for same condition. Is it appropriate for the physician to use the same History and Physical from her first admission? Explain your rationale. What agency or organization governs this area of documentation requirement? Janet Kennedy vaginally delivered a healthy baby boy at Community Hospital.
20170818194409da_and_qa_case_worksheet.docx