(5) Coding and abstracting.
(6) Medical statistics.
(7) Medical transcription.
3-15. PATIENT CARE ASSESSMENT
a. A documentation review of medical records for accuracy, timeliness,
completeness, clinical pertinence, and adequacy as medicolegal documents will be
conducted at least quarterly. This review, in coordination with the medical staff, will be
made on a sample of randomly selected outpatient treatment records, inpatient treatment
records, and health records. Random selection will be based on some characteristic of the
record, such as certain digit(s) or the register number, and not on the nature of the case.
b. Documentation review is made to ensure that the records conform to the
(1) The medical record clearly identifies the patient, the AMEDD treatment
facility, and the treating personnel. In addition, enough information is given to support the
diagnoses, to justify the treatment, and to provide for followup care.
(2) The inpatient treatment records of current inpatients describe the progress
and the current status and treatment of the patient so that the case can be fully understood
at any time. Health records and outpatient treatment records will be reviewed for clinical
pertinence and completeness (i.e., appropriate documentation of visit or episode, up-to-
date problem list, and diagnostic test results filed).
(3) Each medical record includes all completed forms and reports needed by
the nature of the case and the treatment given.
(4) Final diagnoses are fully recorded; symbols and abbreviations have not
(5) All entries are current, clinically pertinent, and legible; entries do not contain
provider accusations or derogatory (ventilated) comments.
(6) All entries are dated and signed.
(7) Discharge instructions, including restrictions, medications, and followup
provisions, are adequate.