HIM 200 Milestone One
November 2, 2022
Specifically, the following critical elements must be addressed:
I. Submit your completed Patient Health Quality Review, evaluating the completeness and accuracy of the provided medical record.
II. Analysis of Health Record: To begin, you will perform an audit on selected medical health record to review and analyze, ensuring that the data required
for patient health management is complete.
A. Based on your review of the medical health record, analyze the contents for defining required patient health data elements:
i. Patient identification
ii. Past health issues
iii. Current health issues
B. Analyze the contents for completeness and accuracy in documenting individual events and encounters. Based on your analysis, define which
data elements are required for the following:
i. Recording patient’s vital signs
ii. Recording health events
iii. Recording medication administration
III. JCAHO: In this section, you will review the Joint Commission Standards as they relate to the health record.
A. Identify the data JCAHO routinely reviews for compliance with information management systems.
B. Evaluate where the record is complete and where it is missing data.
C. Based on the missing data, outline the JCAHO standards where the hospital is deficient.