As the HIM documentation supervisor, you are meeting with the quality improvement (QI) manager to assist in developing an audit template to be used for a quality review of patient record.
Select one of the following documents
- History and physical
- Operative reports
- Discharge summary
Using the Joint Commission website and your textbook, research the standards for your selected document.
Develop a list of required data elements that would be included in the development of an audit data collection tool, inclusive of the time requirement for completion.
- The initial response must be relevant, detailed, and specific, at least 250 words.