Things to Remember:
Clinical Data: Documents medical condition, diagnoses, procedures, and treatments.
Administrative Data: Demographics, financial info, consents, and authorizations.
SOAP format: Subjective, Objective, Assessment, and Plan.
Types of Standards can include Licensure Requirements, Certification Standards, Accreditation Standards, and Facility-Specific Standards.
The Joint Commission:
Accredits a number of different settings.
They do Unannounced surveys.
Annual submission of Periodic Performance Review
Standards for Documentation
Prohibited Abbreviation List
Other accreditation groups include:
American Osteopathic Assc.
Accreditation Assc. for Ambulatory Health Care
Commission on Accreditation of Rehabilitation Facilities
National Committee for Quality Assurance
Others: specialty accrediting groups exist
DNV--began accreditation in US in 2008, gaining acceptance
Sayles; Health Information Management Technology: An Applied Approach