523 The Pastoral Services staff document their
interventions in the record of the patient/resident. |
IM.7 The hospital defines, captures,
analyzes, transforms. Transmits, and reports patient-specific data and information related
to care processes and outcomes. IM.7.1 The hospital initiates and maintains a
medical record for every individual assessed or treated.
IM.7.1.1 Only authorized individuals make entries in medical records.
IM.7.2 The medical record contains sufficient information to identify the patient,
support the diagnosis, justify the treatment, document the course and results, and promote
continuity of care among health care prodders. |