Jcaho Medical Record Guidelines

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Standards for Joint Commission Accreditation and …

https://www.jointcommission.org/standards/

Joint Commission standards help you develop strategies to address the most complex issues and identify key vulnerabilities in the patient care experience. The standards review various aspects of your care delivery process, ensuring a comprehensive review of the …

Records and Documentation - Format/Availability - Joint …

https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/leadership-ld/000001198/

The Joint Commission surveyors will accept evidence of standards compliance in either a paper format or an electronic format. In either case, the …

Documentation Assistance Provided By Scribes - Joint …

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/record-of-care-treatment-and-services-rc/000002210/

At the same time, financial constraints have increased the pressure on physicians and other licensed practitioners (LPs) to see more patients in less time. Yet …

Medical Record - Security - Joint Commission

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/information-management-im/000001462/

The Joint Commission standards require organizations to comply with applicable law and regulation to ensure the privacy and integrity of protected …

Understanding the Requirements - Joint Commission

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/provision-of-care-treatment-and-services-pc/000002272/

An H & P must be completed and entered into the medical record for any high-risk procedure, surgical procedure and any procedure that involves …

Medical Record - Authentication Time Frame - Joint …

https://www.jointcommission.org/standards/standard-faqs/home-care/record-of-care-treatment-and-services-rc/000001691/

The Joint Commission standards do not specify the time frame for authentication of documentation. The organization is free to determine the time frame …

Records and Documentation - Retention - Joint …

https://www.jointcommission.org/standards/standard-faqs/laboratory/leadership-ld/000001197/

Retention of medical records is generally determined by state and/or federal law. Organizations should work with their legal and risk management leadership …

History and Physical - Update …

https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-services-pc/000002112/

When a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required …

Complying With Medical Record Documentation …

https://www.hhs.gov/guidance/document/complying-medical-record-documentation-requirements-fact-sheet

Complying With Medical Record Documentation Requirements Fact Sheet Learn about proper medical record documentation requirments; how to provide accurate …

Record of Care, Treatment, and Services (RC) Standards

https://www.aornguidelines.org/joint-commission/program/46079/standard/46091

RC.02.01.03 The patient's medical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or …

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