Documentation Requirements for the Acute Care Inpatient Record

Categories: CareHealth

The medical record is a tool for collecting, storing, and processing patient information. Records are being used daily for a multitude of purposes, including: providing a means of communication between the physician and the other members of the healthcare team caring for the patient providing a basis for evaluating the adequacy and appropriateness of care providing data to substantiate insurance claims protecting the legal interests of the patient, the facility, and the physician  providing clinical data for research and education ?

General Guidelines for Patient Record Documentation ?• Each hospital should have policies that ensure uniformity of both content and format of the patient record based on all applicable accreditation standards, federal and state regulations, payer requirements, and professional practice standards.

?• The patient record should be organized systematically to facilitate data retrieval and compilation. ?• Only persons authorized by the hospital’s policies to document in the patient record should do so.

This information should be recorded in the medical staff rules and regulations and/or the hospital’s administrative policies.

Get quality help now
checked Verified writer

Proficient in: Care

star star star star 4.9 (247)

“ Rhizman is absolutely amazing at what he does . I highly recommend him if you need an assignment done ”

avatar avatar avatar
+84 relevant experts are online
Hire writer

?• Hospital policy and/or medical staff rules and regulations should specify who may receive and transcribe a physician’s verbal orders. ?• Patient record entries should be documented at the time the treatment they describe is rendered. ?• Authors of all entries should be clearly identifiable. ?• Abbreviations and symbols in the patient record are permitted only when approved according to hospital and medical staff bylaws, rules, and regulations.

All entries in the patient records should be permanent. • Errors should be corrected as follows: draw a single line in ink through the incorrect entry, and print "error" at the top of the entry with a legal signature or initials, date, time, title, reason for change, and discipline of the person making the correction.

Get to Know The Price Estimate For Your Paper
Number of pages
Email Invalid email

By clicking “Check Writers’ Offers”, you agree to our terms of service and privacy policy. We’ll occasionally send you promo and account related email

"You must agree to out terms of services and privacy policy"
Write my paper

You won’t be charged yet!

Errors must never be obliterated. The existing entry should be left intact with corrections entered in chronological order. Late entries should be labeled as such. ?• In the event the patient wishes to amend information in the record, it shall be done as an addendum, without change to the original entry, and shall be clearly identified as an additional document appended to he original patient record at the direction of the patient, who will thereafter bear responsibility for the explaining the change.

The health information department should develop, implement, and evaluate policies and procedures related to quantitative and qualitative analysis of patient records. ?• Review any requirements outlined in state law, regulation, or healthcare facility licensure standards as they relate to documentation requirements. If your state requires that verbal orders be authenticated within a specified time frame, accrediting and licensing agencies will survey for compliance with that requirement.

Cite this page

Documentation Requirements for the Acute Care Inpatient Record. (2018, Sep 22). Retrieved from

Documentation Requirements for the Acute Care Inpatient Record
Live chat  with support 24/7

👋 Hi! I’m your smart assistant Amy!

Don’t know where to start? Type your requirements and I’ll connect you to an academic expert within 3 minutes.

get help with your assignment