Case Study 1.8 Emergency Department Documentation Barbar Harrison

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Case Study 1.8: Emergency Department Documentation 1. Determine the Joint Commission documentation requirements for Emergency Department reports. List them here. Time and means of arrival are documented Documentation in record if patient leaves against medical advice Conclusions at end of treatment Final disposition Condition at discharge Follow-up instructions Copy of ER available to follow-up physician if authorized 2. Audit the five representative ED cases below to determine the major areas in need of documentation improvement. As HIM director, present your results in a short memo to the ED Department Chair, Dr. Wilkerson. time of arrival of the patient is not mentioned. Discharge report and follow up of physician is not mentioned. Document of Discharge treatment advice has to be improved. Condition at discharge has to be documented properly. 3. Create a new section for the medical staff by-laws that incorporates ED documentation requirements.

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