HIM 600 Solved: 2-1 Short Paper: Patient Record Analysis



Record

The Inpatient Face Sheet document for this assignment presents several incomplete or missing sections. Notably, the document is missing the medication administration data, the patient’s diagnostic test results, and the discharge form. Consequently, the year is missing in all the dates provided in the document, with an XXXX notation replacing the year of documentation in the inpatient face sheet document. According to The Joint Commission’s discharge summary standards, a hospital complies if its discharge summary entails the patient s reason for hospitalization, significant findings, treatment and procedure provided to the patient, discharge condition, family and patient instructions as appropriate, and the signature of the attending physician (Gilliam et al., 2017). The provided face sheet document indicates that the attending physician discharged the patient; however, no discharge form is provided, thus, missing further prerequisite information as required by The Joint Commission.        

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