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As more hospitals digitize medical information, accurate record keeping is more important than ever. Yet the most common area of non-compliance in hospitals in 2015 was the Record of Care chapter. All record entries and verbal orders are points of contention with both The Joint Commission and CMS in the hospital CoPs. Hospitals should review this key regulation when updating assessment forms.
|- Authentication of entries||- Reason for admission||- Restraint & seclusion|
|- Care and treatment||- Patient summary requirements||- Discharge information|
|- High-risk procedures||- Demographic information||- Behavioral health|
|- Advance directives||- Medication orders||- Allergies & vital signs|
|- Deleted requirements||- Documentation of operation||And so much more!|