Question

Questions 1-6.

1. Describe common documents found in an acute care setting.
2. Describe the role and responsibility of the doctor, nurse,
and HIM professional that support documentation requirements.

Answer 1

In an acute care setting, common documents include medical records, medication administration records, lab reports, radiology reports, progress notes, and discharge summaries. The doctor's role involves diagnosing and treating patients, while nurses provide direct care and HIM professionals ensure accurate documentation and compliance.

Step-by-step explanation:

In an acute care setting, common documents include:

• Medical records
• Medication administration records
• Lab reports
• Radiology reports
• Progress notes
• Discharge summaries

The role of the doctor involves diagnosing and treating patients, prescribing medications, and overseeing the overall care. Nurses provide direct patient care, administer medications, and communicate with the healthcare team. HIM professionals ensure accurate and complete documentation, manage health records, and ensure compliance with legal and regulatory requirements.