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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:

The xxxxxxxxxx of xxxxxxxxx a xxxxxxxx set xx admission xxxxxxx is xxxxxxx Assessment- x complete xxx of xxxxxxxxx records xxxxx in xxxxxxxx patient xxxxxxxxxx as xx provides xxx complete xxxxxxx history xx the xxxxxxx and xxxxx related xxxxxxxxxxx which xxxxx in xxxxxxxxxxxxx of xxx treatment xx be xxxxx to xxxx Legal xxxxxxxxxxx It xx important xx maintain xxxxxxxx set xx records xx as xx comply xxxx various xxxxx requirements xxxxxxxxxx in xxx healthcare xxxxxx It xxxxxxx the xxxxx which xxx associated xxxx non-compliance xx legal xxxxxxxxxxxx Billing xxxxxxxx The xxxxxxxxx records xxxx a xxxxxxxxxxx role xx billing xxxxxxx It xxxxxxxx the xxxxxxxx information xxxxx the xxxxxxxxxxx coverage xxx helps xx reimbursement xxxxxxx of xxx patient xxxxxxxxx the xxxxxxxxxx chief xxxxxxxxx is xxxxxxxxx before x patient xxx be xxxxxxx is xxxxxxxxx because xxxxxxx it xxxxxxx the xxxxxx of xxx patient xx treatment xx priority xxxxx are xxxxxxxx to xxx patients xxx have xxxxxxx complaints xxxxxxxx it xxxxx in xxxxxxxx the xxxxxx process xx the xxxxxxxxx to xx provided xx the xxxxxxx as xxxxxxxxx patients xxxx different xxxxxxx needs xx the xxxxxxxxx needs xx be xxxxxxx well xx advance x documented xxxxx complaint xxxxxx as xxxxx evidence xx compliance xxxx legal xxx regulatory xxxxxxxxxxxx If x proper xxxxxxxxxx chief xxxxxxxxx is xxxxxxx there xxx high xxxxxxx of xxxxxxx receiving xxxxxxxxxxxxx care xxx to xxxx of xxxxxx documentation xxx medical xxxx might xxxxxxxx to xxxxxxx the xxxxxx diagnosis xx the xxxxxxx In xxx cases xxxxx the xxxxxxx is xxxxxx to xxxxxxxxxxx his xx her xxxxxxxx clearly xxx absence xx chief xxxxxxxxx might xxxx to xxxxxx complications xx the xxxxxxx Therefore xx is xxxxxxxxx to xxxx a xxxxxx documented xxxxx complaint xx that xxxxx is xx miscommunication xxxxxxx the xxxxxxxxxx team xxxxxxx and xxxxxxx diagnosis xxx be xxxxx to xxx patient xxxxxxxxxxxxxxxxxxxx J xxxx Chief xxxxxxxxx is x must xxxx - xxxx Knowledge xxxxxx AAPC xxxxxxxxx Center xxxxx www xxxx com xxxx -chief-complaint-required xxxx The xx is xxx reason xxxxxxxxx to xxxxxxxx the xxxxxxx

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