As a HIM chart analyst, you are reviewing the chart of a patient who was admitted on 2/17 with gallstone pancreatitis.

As a HIM chart analyst, you are reviewing the chart of a patient who was admitted on 2/17 with gallstone pancreatitis.  She arrived through the emergency department on Wednesday afternoon in severe abdominal pain.  After lab work was performed showing an increased lipase level, she was admitted.  Her family physician evaluated her the next morning and ordered an ultrasound and repeat lab work.  The ultrasound showed gallstones, and the lab work indicated the lipase was coming down.  He consulted with a general surgeon, who evaluated the patient and agreed to perform a cholecystectomy on Friday if the lipase level returned to near normal levels.  Surgery was then performed on Friday morning, and after an uneventful night, the patient was discharged home on Saturday morning.  On 2/25, you have the following documentation available in the EHR.  

H&P

Dictated 2/18

Authenticated 2/18

Consultation Report

Dictated 2/18

Authenticated 2/23

Immediate Post-op note

Written 2/19

Authenticated 2/19

Operative Report

Dictated 2/20

Authenticated 2/21

Discharge Summary

Dictated 2/22

Authenticated 

Lab work from all dates of stay

Nursing notes from all dates of stay

Anesthesia documentation from surgery

Physician orders from all dates of stay – all signed

Progress notes – all signed

Medication list – signed

At your facility, the guidelines for record completion are as follows:

• ED reports within 24 hours

• H&P’s within 24 hours of admission

• Operative reports within 24 hours of the procedure with a post-op note present immediately after the procedure

• Consultation reports within 48 hours

• Discharge Summary within 14 days

1. Determine whether the record is complete or not and provide support for your answer.

2. When a record is deemed incomplete, what steps must be taken to get the record completed?

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