| |
Hospital Standards Manual -
Section: Information Management |
|
| |
Standards |
|
| |
The hospital plans for managing
information. |
|
| |
The hospital plans for continuity of its information management
processes. |
|
| |
The hospital protects the privacy of health information. |
|
| |
The hospital maintains the security and integrity of health
information. |
|
| |
The hospital effectively manages the collection of health
information. |
|
| |
The hospital retrieves, disseminates, and transmits health
information in useful formats. |
|
| |
Knowledge-based information resources are available, current,
and authoritative. |
|
| |
The hospital
maintains accurate health information. |
|
| |
|
|
| |
Hospital Standards Manual -
Section: Record of Care, Treatment, and Services (RC) |
|
| |
Medical Records
Documentation Compliance Standards |
|
| |
The hospital maintains complete and accurate medical records for
each individual patient. |
|
| |
Entries in the medical record are authenticated. |
|
| |
Documentation in the medical record is entered in a timely
manner. |
|
| |
The hospital audits its medical records. |
|
| |
The hospital retains its medical records. |
|
| |
The medical record contains information that reflects the
patient’s care, treatment, and services. |
|
| |
The patient’s medical record documents operative or other
high-risk procedures and the use of moderate or deep sedation or
anesthesia. |
|
| |
For hospitals that do not use accreditation for deemed status
purposes: The medical record contains documentation of the use
of restraint and/or seclusion. |
|
| |
The medical record contains a summary list for each patient who
receives continuing ambulatory care services. |
|
| |
Qualified staff receive and record verbal orders. |
|
| |
The hospital documents the patient’s discharge information. |
|
| |
|
|