The document discusses the review of medical charts for completeness regarding patient admissions and surgeries. It highlights the timeline for Health and Physical (H&P) documentation and identifies essential surgical documentation requirements. Specifically, it mentions the review of chart documents for patients Kitty Wells and Jim Caldwell, along with Wendy Jones' surgery documentation.

1. - 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