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Reviewing Health Records

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Running head: Reviewing Health Records
Reviewing Health Records
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Reviewing Health Records 2
Reviewing Health Records
The purpose and function of health records and the collection of accurate patient data
affects the potential result of the patient’s quality of care (ayles, 2013). Data collected and
information analyzed derives from many types of records. For example, assessments and
evaluations information will be obtained from patient, medical, client, and in the case of this
interview, resident records. These avenues for obtaining prudent data are pivotal sources for
information analysis.
Social Service: Interview w/ Health Information
Management Professional
This interview was conducted on a female social service administrator whom has been
employed for 9 years within a long term nursing facility (Anonymity, 2014). During the
interview, documentations, assessments and evaluation reports were the topics of focus. As the
Social Service Administrator, she advised that her position requires due diligence regarding
current patient symptoms, the creation of comfort care plan/s, as well as a mandated self-reporter
when assessment indicate external resources needed. As a result of the interview which only took
about 10-15 minutes, she handed over an admissions evaluations package in which they current
use.
Social Services Procedural Documentation
MDS 3.0 Data Collection Tool (1Page)
Sections are as follows:
Sec I: Language
Sec II: Hearing, Speech, and Vision
Sec III: Cognitive Patterns
a) Brief Interview for Mental Statue (BIMS)
b) Mood
c) Total Severity Score

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Reviewing Health Records 3
Social Service Administration/Discharge Evaluation (5 Pages)
Sections are as follows:
Sec I: General Resident Information
Sec II: Advanced Care
Sec III: Assessment
Sec IV: Discharge Planning
Level 1 Pre-Administration Screening and Resident Review (PASRR) (1 Page)
Sections are as follows:
Sec I: Mental Illness/Development Disability Determination
Sec II: Advanced Categorical Determinations
Sec III: Service Needs and Assessor Data
Social Service Durational Stay Care Plan (1 Page)
Problems
Goals
Interventions
Mood and Behavioral Symptom Assessment/Plan of Care
Psychological Well-Being Mood State (4 pages)
PHQ9 Risk Assessment
Goal
Intervention
Behavioral Symptoms (4 Pages)
Symptoms Assessment
Goals
Interventions
CPR (Cardiopulmonary Resuscitation) Consent
This is a regulatory compliance document that requires lawful consent to consult this particular
exercise when the patient’s life is being threatened.
Documentation Comparison

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