Health Record Content and Documentation

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Across
  1. 2. the standards that a healthcare organization must meet to receive Medicare funding.
  2. 6. the legal authority or formal permission from authorities to carry out certain activities that require such permission
  3. 7. a collection of data items collected on long-term care patients regarding their medical condition and ability to function
  4. 10. the process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature
  5. 11. an official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation
  6. 12. a set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals who are regarded as an authority on a particular subject matter
  7. 18. nature and duration of the symptoms that caused the patient to seek medical attention as stated in his/her own
  8. 19. orders the medical staff or an individual physician established as routine care for a specific diagnosis/procedure
Down
  1. 1. provides accreditation for ambulatory surgery centers, critical access hospitals, hospital home health, hospice, psychiatric hospital
  2. 3. serve to justify further acute-care treatment in healthcare organizations
  3. 4. a summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions
  4. 5. the process of reviewing and validating the qualifications of physicians and other licensed independent practitioners for granting medical staff to provide patient care
  5. 8. the recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers
  6. 9. the reliability and effectiveness of data for its intended uses in operations, decision making, and planning
  7. 13. a federally mandated tool for assessment in long-term care settings designed to provide thorough and systematic appraisal of residents
  8. 14. the documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information
  9. 15. established in the 1960's as an independent, nonprofit accrediting organization to meet the survey needs of various rehabilitation-based healthcare providers
  10. 16. a piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or the president of the United States
  11. 17. the federal agency within the Department of Health and Human Services known for its operational oversight of the Medicare and Medicaid programs
  12. 20. a pattern used in EHRs to capture data in a structured manner and specify the information to be collected