Health Record Content

As a medical record completion supervisor, you are to meet with the HIM director to discuss documentation requirements by which the hospital must abide. The purpose of the meeting is to make sure the policy and procedure for analyzing patient records documentation remain current with regulatory agency documentation requirements.

Create a table to report the different requirements and components for each form in the health record: Discharge summary, progress notes, operative report, pathology report, history and physical.Refer to chapter 4 and visit the Joint Commission website for additional resources.

Grading Rubric

• A table has been created that includes all 5 forms listed.
• Accurate requirements and components of each form are clearly stated.