CH. 4 Health Record Content and Documentation

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Across
  1. 1. Documentation standards have become more detailed and have become focused on____. (3 words)
  2. 4. the health record component that addresses the patient's current complaints and symptoms and lists the patient's past medical, personal, and family history
  3. 6. creates a chronological report of the patient's condition and response to treatment during the hospital stay (2 words)
  4. 10. an information raleting to the physical or mental health or condition of an individual
  5. 11. an industry leader in the area of healthcare provider organization accreditation. (2 words)
  6. 14. standards governing the practice of medical staff members typically voted upon by the organized medical staff and medical staff executive committee and approved by the facility's board of directors. (3 words)
  7. 15. reports provides information on tissue removed during procedure (2 words)
  8. 16. lists of illness, injuries and other factors that affect the health of an individual patient, usually identifying the time occurrence or identifying the time of occurrence and identification and resolution. (2 words)
  9. 17. requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition.
  10. 18. piece of legislation written and approved by state or federal legislature and then signed into law by the state's governor, or President of the U.S.
  11. 19. group focuses on accreditation of rehabilitation programs and services
  12. 21. creates a chronological report of the patient's condition and response to treatment during the hospital stay
  13. 22. Written or spoken permission to proceed with care is classified as___ (2 words)
  14. 23. An official designation indication that the healthcare facilityis in compliance with the medicare CoP (2words)
Down
  1. 2. Data, A patient's gender, phone number, address, next of kin, and insurance policyholder information would be considered what kind of data
  2. 3. an intentional deception or misinterpretation that an individual knows, or should know, to be false or does not believe to be true, knowing the deception could result in some unauthorization benefit to himself.
  3. 5. describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program. It includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced.
  4. 7. A patient's registration forms, personal property list, RAI, care plan, and discharge or transfer documentation would be found most frequently in_____
  5. 8. part of medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in the patient's own words (2words)
  6. 9. recording of pertinent healthcare findings, interventions, and responses to treatment as business records and form of communication among caregivers.
  7. 12. it includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed (2 words)
  8. 13. group focuses solely on accreditation of rehabilitation programs and services
  9. 20. A hospital that participates in the Medicare and Medicaid programs must follow