Question: Section 3: We know that there are policies and standards for everything that is done in healthcare. Policies are set by facilities, while standards are

Section 3: We know that there are policies andSection 3: We know that there are policies and standards for everything that is done in healthcare. Policies are set by facilities, while standards are typically developed by licensing or accrediting agencies. Think about policies that would be related to the HIT field, and specifically to the patient record. Provide examples of data from the sample chart and link them to a common HIT policy or standard. (You must include at least 3 different policies.)

Section 3:

(A) Patient record element/excerpt:

(B) Page #:

(C) Title of form:

(D) Related policy/standard:

Home C Get Homework Help With X C Section 3: We Know That I X + X 21/SU HITT-1301-721: Final x B Medical Record for Course x c Get Homework Help With X File C/Users/danam/Downloads/Medical-Record-for-Course Project%20(2).pdf c @ To 2 4 of 28 Q + EBD Page view A Read aloud V Draw Highlight Erase + TON, RETH IPCase001 DE. BLACK DISCHARGE SUMMARY Mission 14/25/YYYY DOE: 12/17/YYYY BOX 360 ADMISSION DATE: 04/26/YYYY DISCHARGE DATE: 04/30/YYYY ADMISSION DIAGNOSIS: Fever of undetermined origin. DISCHARGE DIAGNOSIS: Neute pyelonephritis. SUMMARY: This 30 year old white fenale had high fever off and on for several days prior to admission without any localizing signs or symptoms. Preliminary studies donc as an outpatient were unremarkable except to indicate an infection some place. She was ultimately seen in the office, temperature was 103 to 104. She was becoming dehydrated, washed out, weak, tired, and she was admitted for further workup and evaluation. Workup included a chest x-ray, which was romel. Intravenous pyelogram was also normal. Blood culture report was normal. Urine culture grew out Escherichia coli greater than 100,000 colonies. Throat culture was normal. Onc blood culture did finally grow out an alpha strep viridans. I talked to Dr. Burke about this and we decided on the basis of her clinical condition and the fact that this did not grow on all bottles it was more likely a contaminate. Urine showed a specific gravity of 1.010, albumin 1+, sugar and acetone were negative, white blood cells 5 to 9, and red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1, segmental cells 81, lymphocytes 11, nanocytes 5, eosinophila 1, bands 2. dosis test was negative. Alkoline i bande 2. phosphatase 127, sugar 125, sodium 142, pot 288ium 4.7, carbon dioxide 30, chloride 104, cholesterol 119, Serun glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151, creatinine 0.9, calcium 9.6, phosphorus 3.3, bilirubin 0.6, total protein 6., albumin 1.0, uric acid 6.5. Electrocardiogram was reported as normal. She was started on intravenous fluids, intravenous Keflex, ter temperature remained elevated for approximately 48 hours and now has been normal tox the last 48 to 72 hours. She feels better, hydration is better, eating better, no urinary symptoms. She's being discharged at this time on Keflex 500 four times per day, increased fluid intake. To be seen in follow up in the office in a week. DD: 01/30/YYYY Reviewed and Approved: John Black ND ATP-B-5:02: 1001261385: John Black ND Signed: 5/1/YYYY 2:24:44 PM EST Physician Authentication DT: OSOL/YYYY AURRERES INDEM WIRELLI W Type here to search O 92F Mostly sunny 1:16 PM B/14/2021 Home C Get Homework Help With X C Section 3: We Know That I X + X 21/SU HITT-1301-721: Final x B Medical Record for Course x c Get Homework Help With X File C/Users/danam/Downloads/Medical-Record-for-Course Project%20(2).pdf c @ To 2 4 of 28 Q + EBD Page view A Read aloud V Draw Highlight Erase + TON, RETH IPCase001 DE. BLACK DISCHARGE SUMMARY Mission 14/25/YYYY DOE: 12/17/YYYY BOX 360 ADMISSION DATE: 04/26/YYYY DISCHARGE DATE: 04/30/YYYY ADMISSION DIAGNOSIS: Fever of undetermined origin. DISCHARGE DIAGNOSIS: Neute pyelonephritis. SUMMARY: This 30 year old white fenale had high fever off and on for several days prior to admission without any localizing signs or symptoms. Preliminary studies donc as an outpatient were unremarkable except to indicate an infection some place. She was ultimately seen in the office, temperature was 103 to 104. She was becoming dehydrated, washed out, weak, tired, and she was admitted for further workup and evaluation. Workup included a chest x-ray, which was romel. Intravenous pyelogram was also normal. Blood culture report was normal. Urine culture grew out Escherichia coli greater than 100,000 colonies. Throat culture was normal. Onc blood culture did finally grow out an alpha strep viridans. I talked to Dr. Burke about this and we decided on the basis of her clinical condition and the fact that this did not grow on all bottles it was more likely a contaminate. Urine showed a specific gravity of 1.010, albumin 1+, sugar and acetone were negative, white blood cells 5 to 9, and red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1, segmental cells 81, lymphocytes 11, nanocytes 5, eosinophila 1, bands 2. dosis test was negative. Alkoline i bande 2. phosphatase 127, sugar 125, sodium 142, pot 288ium 4.7, carbon dioxide 30, chloride 104, cholesterol 119, Serun glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151, creatinine 0.9, calcium 9.6, phosphorus 3.3, bilirubin 0.6, total protein 6., albumin 1.0, uric acid 6.5. Electrocardiogram was reported as normal. She was started on intravenous fluids, intravenous Keflex, ter temperature remained elevated for approximately 48 hours and now has been normal tox the last 48 to 72 hours. She feels better, hydration is better, eating better, no urinary symptoms. She's being discharged at this time on Keflex 500 four times per day, increased fluid intake. To be seen in follow up in the office in a week. DD: 01/30/YYYY Reviewed and Approved: John Black ND ATP-B-5:02: 1001261385: John Black ND Signed: 5/1/YYYY 2:24:44 PM EST Physician Authentication DT: OSOL/YYYY AURRERES INDEM WIRELLI W Type here to search O 92F Mostly sunny 1:16 PM B/14/2021

Step by Step Solution

There are 3 Steps involved in it

1 Expert Approved Answer
Step: 1 Unlock blur-text-image
Question Has Been Solved by an Expert!

Get step-by-step solutions from verified subject matter experts

Step: 2 Unlock
Step: 3 Unlock

Students Have Also Explored These Related General Management Questions!