Question.1474 - Week 6: Discussion - Health Care Settings James Lewis 77 unread replies.1818 replies. Week 6: The hospital inpatient record includes administrative data (e.g., demographic, financial, socioeconomic), which is gathered upon admission of the patient to the facility. Reports that comprise administration data include the face sheet (or admission/discharge record), advance directives, informed consent, patient property form, and birth certificate. When a patient is admitted to the hospital through the ED or ER, the first clinical data item is the chief complaint documented as part of the ED/ER record. Other clinical data documents include the discharge summary, history and physical examination, consultation, progress notes, nurses’ notes, and so on. Discuss the importance of obtaining a complete set of admission records described above. Why, or why not, is obtaining the documented chief complaint necessary before a patient can be treated! Discuss the potential for someone receiving either appropriate or inappropriate care should the chief complaint is missing or not sufficiently documented. Discussion Guidelines: Each week you will have a topic to answer and then respond to at least two classmates. This means, that if you follow the minimum posting requirements you will have one main substantive answer in each thread, and one response to at least two classmates. Altogether 3 posts, 2 of which will be on different days of the week. Be sure to check in if you have questions. Grading rubric for discussion posting per thread: Main post - 10 points (high quality) Response posts - 10 points (total of all responses) Post by Wednesday - 5 points
Answer Below:
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