Health Information Technologies & Processes

Latest Discussion Posts

  • For us H&P not done within 24 hours of admission or prior to surgery is considered delinquent.  Consults need to be on the chart within 24 hours of the consult. For OP notes- we require a post op note be on the patient chart prior to the patient transitioning ...

  • Good morning all ! The facility I currently work with does not have a signature log process in place for providers (nursing/physicians) so we find it challenging when trying to verify providers when analyzing charts and when we receive requests from ...

  • Hello Karen, we created a Medical Record Content Policy to help with this. The medical staff bylaws also has supportive requirements that the medical staff have to adhere to. I can share our MRCP with you if that helps. Thanks, Karla ...

  • ​we are in a continuous state of readiness to assure documentation is consistent with continuity of care, complete and accurate entries as well as meeting regulatory requirements.  All that being said , an audit suggestion is to develop or have handy ...

  • Hello I am hoping someone can direct me to or share with me the Joint Commission regulations or standards regarding the record of care in an acute care hospital setting. I wish to know what documents are required to be recorded and what is required to ...