A 45 -year-old female has requested a copy of her 80-year-old father’s health record. She has presented POA and has a legal right to access his records

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A 45 -year-old female has requested a copy of her 80-year-old father’s health record. She has presented POA and has a legal right to access his records. You provide a copy to the woman, but she has many questions regarding documentation of her father’s diagnosis. He was admitted to the ICU last week from the skilled nursing facility. When discharged, he was transferred to a LTCH. In a brief written response to the woman, relate the components of the health record that supports diagnosis and reflects the patient’s progress, clinical findings, and discharge status. Explain the documentation used for these purposes within skilled nursing

facilities, ICU, and LTCH.

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