List of Required Medical Documents?
I'm having a hard time finding information on a list of required documents that four types of facilities would have. I've tried looking online and nothing seems to be coming up. I've tried CMS.gov with no luck. I need a list of documents that would transverse from paper to electronic health records. The places are a hospital, rehab center, nursing home, home health, and a clinic. I already know every one of them need administrative information (patient name, age, etc.). I also need to know what clinical information systems might be implemented that can be used by all entities?
- moniqueLv 77 years agoFavorite Answer
Appendix PP- Nursing Home Regs http://www.cms.gov/Regulations-and-Guidance/Guidan...
Appendix B- Home Health Regs http://www.cms.gov/Regulations-and-Guidance/Guidan...
Appendix A- Hospital Regs http://www.cms.gov/Regulations-and-Guidance/Guidan...
By types of documents, I am not sure if I understand..........but I am going to try and answer..... Hospitals, Nursing Homes and Home Health will definitely have skin assessments as well as other nursing assessments, dietary assessments (home health may not have these per say since they don't staff registered dieticians), physicians' notes, medications prescribed, allergies, and discharge summaries.Source(s): health care regulatory experience