For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

As part of quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records the best place in the record to locate this information is the

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman.

As a new CTR, you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility’s