https://law.lis.virginia.gov/admincode/title12/agency5/chapter410

Joint commission medical record review-table.docx

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=3e51da933336e37b7f825c0f161f21a2&ty=HTML&h=L&r=PART&n=pt42.5.482#se42.5.482_124 (Links to an external site.)

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The Policy for the Medical Record
In accordance with TJC, CoP and the state of VA, each patient will have a complete medical record. (T/F)
In accordance with TJC, CoP and the state of VA, every medical record must be authenticated, dated and
time stamped. (T/F)
(If you agree with these statements, be sure to include it in your formal letterhead policy and
procedures.)
Patient Identification
To be within the accordance of the CoP, the facility will collect the following information from the
patient in order to identify the patient:
To satisfy the TJC, the facility will collect the following information from the patient as a requirement for
identifying the patient:
History and Physical (H&P)
In accordance with the CoP, the H&P will be completed for each patient by when:
In accordance with TJC, the H&P will be completed for each patient by when:
To satisfy the CoP requirements, the H&P must be completed prior to what type of procedures:
To satisfy TJC requirements, the H&P must be completed prior to what type of procedures:
Operative Report
To satisfy the CoP requirements, the following items must be included in the operative report for the
patient:
To satisfy TJC requirements, the following items must be included in the operative report for the
patient:

If the patient is at higher risk for the operation, the facility must include ______________________
documentation to satisfy the CoP requirements.
If the patient is at a higher risk for the operation, the facility must include ____________________
documentation to satisfy TJC requirements.
Verbal Orders
According to the CoP, the ____________________ can receive verbal orders from a physician.
According to TJC, the __________________ can receive verbal orders from a physician.
The CoP requires these verbal orders to be authenticated within ___________________ timeframe.
TJC requires these verbal orders to be authenticated within __________________ timeframe.
The following information must be collected in addition to the verbal order to satisfy the CoP
requirements:
The following information must be collected in addition to the verbal order to satisfy TJC requirements:
Discharge Summaries
To satisfy both the CoP and TJC, __________________ will have a discharge summary when he/she is
discharged from the facility.
In accordance with the CoP, the discharge summary will include the following information:
In accordance with TJC, the discharge summary will include the following information:
Timeliness
To be in accordance with the CoP, the medical record must be completed within __________________
timeframe.
To be in accordance with TJC, the medical record must be completed within _____________________
timeframe.
To be in accordance with the state of VA, the medical record must be completed within
________________ timeframe.
To satisfy TJC timeframe for completed medical records, TJC allows for _______________ percentage
delinquency rate for the completion.
Record Retention
To comply with the CoP, the patients’ medical records will be retained for ________________ years
from last date of service.
To comply with TJC, the patients’ medical records will be retained for __________________ years from
last date of service.
To comply with the state of VA, the patients’ medical records will be retained for _______________
years from last date of service.

Thanks for the help

Complete Answer: