Sunday, September 15, 2013

Week 3

Things to Remember:

Chapter 3
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

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