Final answer:
The health record per The Joint Commission (TJC) must contain sufficient information to identify the patient, support the diagnoses, justify the treatment, document the course and results, and facilitate community of care.
Step-by-step explanation:
The health record per TJC must contain sufficient information to identify the patient, support the diagnoses, justify the treatment, document the course and results, and facilitate community of care.
Organizations such as HIPAA, CMS, HFAP, and TJC have guidelines for health record documentation to ensure patient care quality and continuity. The Joint Commission (TJC) is a non-profit organization that accredits and certifies healthcare organizations, including hospitals.
When it comes to the health record, these organizations emphasize the importance of including accurate patient identification information, detailed documentation of diagnoses and treatments, progress notes, and the outcomes of care. This information helps support continuity of care, communication among healthcare providers, and the overall quality of patient care.