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OPEN RECORD REVIEW (IM.6.20)
OPEN RECORD REVIEW (IM.6.
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Identification information includes:
Identification informatio
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Patient’s name
Patient’s name
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Description
Description
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Sex
Sex
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Address
Address
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Date of Birth
Date of Birth
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Authorized representative, if applicable
Authorized representative
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0
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3
100
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Legal status of patients receiving behavioral health care services
BHC legal status
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0
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1
3
0
true
1
100
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Emergency care provided to the patient before his or her arrival if any
Emerg care provided
0
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7fdf4479-3295-4228-9a26-9b9ef252152f
0
0
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3
0
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3
100
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Documentation and findings of assessments
Assessments and findings
0
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0
0
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1
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0
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1
100
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Conclusions or impressions drawn from medical history and physical examination
Conc/Impression from H&P
0
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0
0
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3
0
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1
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The diagnosis, diagnostic impression, or conditions
Dx, Impression, Condition
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0
0
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1
3
0
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1
100
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The reason(s) for admission or care, treatment, and services
Reason for Admit
0
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0
0
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1
3
0
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1
100
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The goals of the treatment and treatment plan
Goals/Treatment Paln
0
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0
0
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1
3
0
true
1
100
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Evidence of known advance directives
Advance Directive
0
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0
0
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3
0
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1
100
fa3f9b39-7e6b-4f6c-864c-bd9fdf5332c0
Evidence of informed consent when required by organization policy
Informed Consent
0
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0
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3
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Diagnostic and therapeutic orders
Dx/Rx Orders
0
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0
0
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1
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All diagnostic and therapeutic procedures, tests, and results
All diagnostic and therap
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0
0
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0
true
1
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Progress notes made by authorized individuals
Progress Notes
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0
0
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3
0
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1
100
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All reassessments and plan of care revisions, when indicated
Reassess/Care Plan Revise
0
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0
0
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1
3
0
true
1
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Relevant observations
Relevant observations
0
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0
0
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1
3
0
true
1
100
bac62ceb-11d5-49a3-852c-b3e51a62bf51
The response to care, treatment, and services provided
Response to care
0
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7fdf4479-3295-4228-9a26-9b9ef252152f
0
0
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1
3
0
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1
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Consultation reports
Consultation reports
0
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0
0
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1
3
0
true
1
100
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Allergies to foods and medicine
Food/Medicine Allergy
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0
0
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3
0
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1
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Every medication ordered or prescribed
Med Prescribe\Order
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0
0
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1
3
0
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1
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Every dose of medication administered includes
Dose of Med Includes
0
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0
0
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Strength
Strenth
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0
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Dose
Dose
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0
0
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1
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Rate of administration
Rate of administration
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0
0
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2
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0
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1
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Administration devices used
Admin Devices Used
0
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0
0
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0
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Access or route
Access or route
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0
0
31
2
3
0
true
1
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Known drug allergies
Known drug allergies
0
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0
0
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1
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Adverse drug reactions
Adverse drug reactions
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0
0
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1
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Any adverse drug reaction
Any adverse drug reaction
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0
0
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2
3
0
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1
100
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Records of communication with the patient regarding care, treatment, and services, for example, telephone calls or email, if applicable
Records of communication
0
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0
0
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1
3
0
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1
100
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Patient-generated information (for example, information entered into the record over the Web or in previsit computer systems), if applicable
Patient-generated informa
0
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0
0
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ccd7be4f-79c5-4ab4-84df-5ae693484c67
CLOSED RECORD REVIEW (IM.6.20)
CLOSED RECORD REVIEW (IM.
0
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ccd7be4f-79c5-4ab4-84df-5ae693484c67
1
1
0
0
3
2
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1
100
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Every medication dispensed and prescribed on discharge
Every medication dispense
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ccd7be4f-79c5-4ab4-84df-5ae693484c67
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1
3
0
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1
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All relevant diagnoses/conditions established during the course of care, treatment, and services, for example, telephone calls or email, if applicable
All relevant diagnoses/co
0
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1
3
0
true
1
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LEGIBILITY
LEGIBILITY
0
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96673718-2686-4758-8a3d-d265b659ca50
2
2
0
0
3
2
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1
100
dd8e97e2-e0a3-4507-8f84-f8266298cb9d
Are medication orders readable
MED orders readable
0
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96673718-2686-4758-8a3d-d265b659ca50
2
2
1
1
3
0
true
1
100
eebd07fd-0526-4a25-b24e-279912823dc8
Are physicians progress notes readable?
MD prog notes readable
0
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96673718-2686-4758-8a3d-d265b659ca50
2
2
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1
3
0
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1
100
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Is nursing documentation readable
Nursing doc readable
0
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96673718-2686-4758-8a3d-d265b659ca50
2
2
3
1
3
0
true
1
100
02deb19a-d5b2-4e58-9e09-2b916a343dfc
Is the documentation for other clinical disciplines readable
Clinical Notes Readable
0
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96673718-2686-4758-8a3d-d265b659ca50
2
2
4
1
3
0
true
1
100
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VERBAL ORDERS
VERBAL ORDERS
0
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3
0
0
3
2
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1
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Dated
Dated
0
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1
3
0
true
1
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Timed
Timed
0
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3
3
2
1
3
0
true
1
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Signed
Signed
0
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3
3
3
1
3
0
true
1
100
de57ee84-ed96-4d8b-8dd7-e6538e005fbf
Read back
Read back
0
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3
3
4
1
3
0
true
1
100
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Ledgible
Ledgible
0
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5f86c788-89fb-406c-b5c4-61b59f3fffe1
3
3
5
1
3
0
true
1
100