Call/WhatsApp: +1 914 416 5343

Health Record Content and Documentation

1. Identify the accrediting or certifying body that address each of the following types of healthcare settings (an internet search can be utilized for assistance).

Type of Healthcare Setting Accrediting and Certifying Organizations
Acute care hospitals
Ambulatory care or physician office settings
Ambulatory surgery facilities
Long-term care facilities
Behavioral healthcare facilities
Obstetric or gynecologic care settings
Rehabilitation services organizations

2. Identify the type of consent, authorization, or acknowledgement based upon the description provided:

Consent Type Consent Document Language
The protections afforded to individuals who are undergoing medical procedures
in hospitals or other healthcare facilities
The type of permission that is inferred when a patient voluntarily submits to
The spoken or written permission granted by a patient to a healthcare provider
that allows the provider to perform medical or surgical services
Healthcare providers must provide the patient an explanation as to how the healthcare provider will use or disclose the patient’s PHI, as well as how the healthcare provider will safeguard the PHI in its possession, as well as what rights can be exercised by the patient.
The patient has given the physician or other healthcare provider permission to touch him or her.
Required under the Privacy Rule for the use and disclosure of protected health information. Provides the healthcare provider the authority to use or disclose patient protected health information for a specific purpose.
Patients acknowledge that the healthcare provider is not responsible for any loss or damage of the patient’s belongings,
A legal term referring to a patient’s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed

3. Identify the acute-care record component where the following information would be found.

a. I hereby acknowledge that Dr. Anyone has provided information about the procedure described above, about my rights as a patient, and he or she answered all questions to my satisfaction. Dr. Anyone has explained the risks and benefits of this procedure to me.

b. Patient name, date of birth, patient gender, next of kin information

c. You authorize your physician or other qualified medical providers to perform medical treatment and services on your behalf.

d. I understand that I have a right to restrict the manner in which my protected health information is used and disclosed to carry out treatment, payment, or healthcare operations.