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- Quantitative (record completenessdocuments are present, forms authenticated) 4. Mrs, Kitty Wells was admitted today, November 14, 2019, and upon review of her chart it was noted that an H\&P was found dated from October 18, 2019. Mrs. Wells has not had any significant changes to her medical history or condition since her last appointment with her physician. - Is this an acceptable timeframe for her H\&P? 5. Mr. Jim Caldwell presented for a colon resection surgery this morning at 8:00 am. - What specific document must have been on the chart prior to surgery? - What specific document must be dictated ASAP and no later than 24 hours of surgery? 6. You are reviewing the chart for completeness of documentation for Wendy Jones' surgery on October 2 5 th . You were able to locate the following items: - H\&P - Pre-Op anesthesia evaluation - Intra-Op documents - Operative report - Discharge summary.

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- Quantitative (record completenessdocuments are present, forms authenticated) 4. Mrs, Kitty Wells was admitted today, November 14, 2019, and upon review of her chart it was noted that an H&P was found dated from October 18, 2019. Mrs. Wells has not had any significant changes to her medical history or condition since her last appointment with her physician. - Is this an acceptable timeframe for her H&P? 5. Mr. Jim Caldwell presented for a colon resection surgery this morning at 8:00 am. - What specific document must have been on the chart prior to surgery? - What specific document must be dictated ASAP and no later than 24 hours of surgery? 6. You are reviewing the chart for completeness of documentation for Wendy Jones' surgery on October 2 5 th . You were able to locate the following items: - H&P - Pre-Op anesthesia evaluation - Intra-Op documents - Operative report - Discharge summary

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