Registered Health Information Administrator

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat i...

An example of objective entry in the health record supplied by a health care practitioner is the

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standar...

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond con...

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery,...