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There are two (2) parts to the assignment. In Part 1, you will be accessing the Conditions of Participation to review the standards and complete the grid in Part 1.
In Part 2, you will utilize the information you obtained from the COP in Part 1 to audit the "Sample Medical Record Requirements Policy" for compliance with the standards.
Part 1
Instructions:
Column A
Column B
Element
Standards
(Responses should reflect the full intent of the COP Standard)
Example:
Standing Orders
1. Medical Record Maintained
2. Retention
3. Coding & Indexing
4. Release of Original Medical Records
5. Medical Record Entries and authentication
6. Orders
7.History & Physical (H&P) completion timeframes-
a) Preadmission
b) After admission
c) Surgery with Anesthesia
d) Updated H&P
8. Other record content includes (except discharge summary, final diagnosis and completion of medical record)
9. Discharge Summary Content
10. Final Diagnosis and Medical Record Completion Timeline
Part 2
Mark "X" in the appropriate column.
Note: Only one "X" per element.
Column C
Column D
Column E
COP Required Elements
Present Correct
Mark "X"
Not Present
Present Incorrect
Record the Correct Statement per COP 482.24
X
May be used if such orders and protocols have been reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership
5. Medical Record Entries
7. History & Physical (H&P) completion timeframes-
(a - d)
d) Updated H&P
8. Record content includes (except discharge summary, final diagnosis and completion of medical record)
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